im 


^  i- 


'i 


\m 


i  i>!i 


PlnF 


liilt     !i 


iii-     ■:  I 


mm 


W  41 


ili:  ,' 


i     HUli 


ili  1; 


«<."!Uii(ii<jU4iiliii(iiiiHMiituiiujiiiiiiiiliiuiiii 


DIARRHEAL,  INFLAMMATORY, 
OBSTRUCTIVE,  AND 
PARASITIC  DISEASES 

OF  THE  GASTRO-INTESTINAL  TRACT 


BY 


SAMUEL  GOODWIN  6aNT,  M.  D.,  LL.  D. 

PROFESSOR  OF  DISEASES  OF  THE  COLON,   SIGMOID  FLEXURE,  RECTUM,  AND  ANUS  AT  THE 
NEW   YORK    POST-GRADUATE   MEDICAL   SCHOOL   AND   HOSPITAL 


ILLUSTRATED 


PHILADELPHIA   AND   LONDON 

W.    B,    SAUNDERS    COMPANY 

191  S 


Copyright,  1915,  by  W.  B.  Saunders  Company 


PRINTED    IN    AMERICA 

PRESS    OF 

W.    B.    SAUNDERS    COMPANY 

PHILADELPHIA 


PREFACE 


The  generous  reception  given  the  author's  recently  pubHshcd 
work  on  Constipation  and  Intestinal  Obstruction  {Obstipation — Intes- 
tinal Stasis)  lias  encouraged  him  in  the  beHef  that  a  volume  along 
similar  lines  devoted  to  Diarrheal,  Inflammatory,  Obstructive,  and 
Parasitic  Diseases  of  the  Gastro-intestinal  Tract  would  be  of  value 
to  the  profession. 

The  dominant  idea  of  the  author  in  the  preparati(Mi  of  this  work 
has  been  to  present  to  students  and  practitioners  a  complete  yet 
practical  treatise  covering  the  etiology,  pathology,  s>-mptoms,  diagno- 
sis, and  treatment  of  acute  and  chronic  diarrhea  and  allied  affections,  as 
well  as  diseases  consequent  upon  gastro-intestinal  parasites. 

To  free  the  book  of  useless  material  and  make  it  convenient  in  size 
and  easily  comprehensible,  the  author's  discussions  have  been  as  brief 
as  justice  to  the  subject  would  permit,  and  technical  terms,  confusing 
nomenclature,  profuse  histologic  data,  complicated  laboratory  meth- 
ods of  examination,  prolonged  discussion  of  mooted  points,  wearying 
statistic  tables,  and  obsolete  views  have  been  omitted.  He  has  also 
endeavored  to  arrange  the  subjects  in  a  logical  and  convenient  form,  so 
that  the  busy  practitioner  or  student  may  quickly  refer  to  whate^•er 
he  desires  relative  to  diarrheal  and  parasitic  afl"ections. 

Many  times  the  author  has  desired  information  concerning  certain 
phases  of  diarrhea  and  has  been  unable  to  find  it  except  by  culling  an 
enormous  amount  of  current  literature,  which  required  considerable 
time  and  labor,  and  repeated  experiences  of  this  kind  helped  to  con- 
vince him  that  a  volume  which  would  cover  diarrhea  in  all  its  phases 
would  prove  useful  alike  to  the  internist,  pediatrist,  and  surgeon.  He 
has  also  been  asked  man\'  times  by  physicians  why  he  was  devoting  so 
much  lime  and  space  to  Diarrhea,  a  generally  recognized  and  easily 
controllable  manifestation.  In  reply  he  would  say  that  through  the 
frequent  questioning  of  students  and  practitioners  with  whom  he  has 
come  in  contact  while  lecturing  in  different  cities  and  teaching  at  the 
New  York  Post-Graduate  Medical  School  and  Hospital,  and  at  the 
University  and  Womens'  Medical  (\)lleges  (Kansas  Gity,  Mo.),  the 
author  has  become  convinced  that  physicians  generalh-  do  not  under- 
stand the  various  types  of  diarrhea,  the  mod(>rn  methods  of  ditler- 
entiating  them,  nor  the  beneficent  results  wliicli  follow  their  treatment 
by  directly  irrigating  the  lesions  responsible  for  the  loose  movements 
or  by  surgical   measures;  and   further,   that  a   more  comprehensive 

9 


lO  PREFACE 

knowledge  relative  to  diarrheal,  inflammator\'.  and  parasitic  diseases 
of  the  intestine  in  all  their  phases  is  desirable. 

On  account  of  the  ver>-  great  interest  manifested  concerning 
tropical  and  parasitic  diseases  (frequent  factors  in  diarrhea)  at  home 
and  in  our  colonies,  and  the  numerous  discoveries  recently  made  per- 
taining to  their  etiolog>%  patholog\%  symptoms,  diagnosis,  and  treat- 
ment, the  author  has  fully  discussed  the  relation  of  Parasitic  Diseases 
to  Diarrhea. 

Distinctive  chapters  have  also  been  devoted  to  a  "Formulary" 
and  the  "Irrigating"  and  "Surgical  Treatment"  of  Diarrheal  and 
Parasitic  Aflfections  of  the  Gastro-intestinal  Tract. 

So  much  progress  has  been  made  during  the  past  few  years  in  the 
methods  of  examination  and  diagnostic  technic  relative  to  diarrhea, 
parasitic  and  other  gastro-intestinal  altections.  that  it  has  been  deemed 
wise  to  discuss  them  in  a  general  way  in  the  special  chapter  entitled, 
''Examination  and  Diagnosis,"  and  again  in  greater  detail  when  con- 
sidering their  relation  to  indi\idual  forms  of  diarrhea  in  other  sections 
of  the  work. 

The  author  wishes  to  take  this  opportunity  to  thank  Dr.  Lamb,  of 
the  Army  Medical  Museum,  for  procuring  photographs  of  specimens; 
Drs.  S.  Mortimer  Hill  and  F.  Robbins  for  assistance  rendered  during 
the  preparation  of  the  work;  Messrs.  Howard  J.  Shannon  and  K.  K. 
Bosse  for  the  excellent  drawings  seen  throughout  the  book;  E.  F. 
Rinn  for  retouching  numerous  photographs;  and  the  \V.  B.  Saunders 
Company  for  the  many  courtesies  extended  to  the  author. 

With  the  hope  that  his  work  may  stimulate  interest  in  the  class  of 
diseases  discussed,  and  prove  helpful  in  the  recognition  and  manage- 
ment of  diarrheal,  inflammaton.-.  obstructive,  and  parasitic  atYections 
of  the  gastro-intestinal  tract,  the  author  ofTers  this  book  to  members 
of  the  profession. 

S.\2kiUEL  GooD^^^x  Gaxt 
171  P.\rk;  An'exuz, 

Xew  York  Crr\\ 
May,  igis. 


CONTENTS 


CHAPTER    I  Page 

Introduction  and  Classification 17 

CHAPTER    H 

Examination  antd  Diagnosis 24 

CHAPTER    HI 

Organic  Diseases,  Diarrhea  in 54 

Eye  Diseases,  54 — Mouth  Diseases,  54 — Nasopharyngeal  Diseases,  55 — Thyroid 
Diseases,  56 — Liver  Diseases,  58 — Pancreatic  Diseases,  60 — Kidney  Diseases, 
62 — Diabetes  Mellitus,  63 — Suprarenal  Disease,  64 — Genital  Diseases,  64 — 
Skin  Diseases,  67 — Bone  Diseases,  68. 

CHAPTER    l\ 

Amyloidosis  of  the  Lxtestinal  Tract  (Lardaceous  Degeneration),  Diakmiea 
IN 69 

CHAPTER   V 

Acute  Infectious  and  Contagious  Diseases,  Diarrhea  in 72 

Measles,  74 — Scarlet  Fever,  74 — Varicella,  74 — Variola,  75 — Whooping-cough, 
75 — Diphtheria,  75 — Influenza,  75 — Pneumonia,  76 — Malaria,  78. 

CHAPTER   VI 

Acute  Infectious  and  Contagious  Diseases,  Diarrhea  in  (Concluded) 70 

Typhoid  Fever,  jg — Yellow  Fever,  79 — Relapsing  Fever,  81 — Cholera,  81 — Spor- 
adic Cholera,  84 — Winter  Cholera,  86 — Sepsis,  89 — Erysipelas,  qo. 

CHAPTER   VII 

Miscellaneous  Infectious  Diseases,  Diarrhea  in 91 

Cochin-China  Diarrhea,  92 — Sprue,  93 — Hill-diarrhea,  94 — Diarrhea  Alba,  94 — 
Pseudodysenteric  Diarrhea,  94 — Anthrax,  96 — Malaria,  96 — Typhus  Fever,  96 
— Plague,  97 — Clanders,  97 — Sutika,  97 — Intestinal  Myiasis,  98 — El  Bicho 
Diarrhea,  99 — Pellagra,  99 — Actinomycosis,  101. 

CHAPTER   \in 

Sundry  Diseases,  Diarrhea  in 103 

Coprostasis,  103 — Obesity,  106 — Cachexia,  108 — Anemia,  108 — Pernicious 
Anemia,  109 — Leukemia,  109 — Alcoholism,  no — Marasmus,  112 — Arterio- 
sclerosis, 112 — Enteritis  Crouposa  Nccrotica,  112 — Gout,  113 — Methemo- 
globinemia, 113 — Scurvy,  113 — Cerebrospinal  Meningitis,  113. 


12  CONTEXTS 

CHAPTER    rX  Page 

SrXDRY  Dr.\RRHEAS 114 

Diarrhea  from  Irregularities  in  Living.  114 — Diarrhea  Cathartica.  115 — Diar- 
rhea in  H\-pod>-namia  Cordis.  116 — Bums.  116 — .\goraphobia.  117 — Sito 
phobia.  117 — Chilling.  iiS — Drinking  Water  and  Cold  Beverages.  119 — 
Sun-strokes  and  Heat-strokes.  120 — Old  Age.  121 — Diarrhea  Xoctuma.  121 — 
Eosinophilic  Diarrhea,  121 — Mechanic  Diarrhea.  122 — Diarrhea  from  Reflex 
Disturbances,  122. 

CH.APTER   X 

G.A.STROGEXIC  Di.\RRHEA  (Dyspeptic  Dl\rrhea.  Liexteric  Diarrhea) 123 

Achylia  Gastrica,  123 — H)-peracidity,  123 — Malignancy.  123 — Atony,  123 — 
^fotor  Insufficiency,  123. 

CIL\PTER   XI 

EXTEROGEMC    Dl^RRHEA    (DYSPEPTIC    Dl\RRIIEA.    LiEXTERIC   DiAILRHEA) I32 

Unbalanced  Succus  Entericus,  132 — Duodenal  Ulcer,  132. 

CIL\PTER  Xn 

NElJROGE^^c    Diarrhea    (Fuxctioxal.    Postpr.\xdial    Diarrhea,    Xocturnal 

Di.vrrhea) 138 

Psychic  Diseases  and  Injuries  of  the  Xer\ous  Sjstem,  13S — Reflex  Disturb- 
ances, 138 — .\fFections  of  the  Thyroid  Gland,  138. 

CH.APTER   Xm 

Toxic  Diarrhea 150 

[Meat-poisoning,  150 — Toxemia  from  Meat  of  Diseased  Animals,  151 — Toxemia 
from  Decayed  or  Putrefied  Meat,  152 — Toxemia  from  Sausage-poisoning.  152 
— Poisoning  from  Milk  and  Iti  Products,  152 — Fish  and  Shell-fish  Poisoning, 
154 — Poisoning  from  Canned  Goods.  155 — Potato  Poisoning.  156 — Mush- 
room (Muscarin)  Poisoning.  157 — Grain-  or  Seed-poisoning.  158 — Other 
Food  Diarrheas,  158. 

CiL\PTER   XIV 

Toxic  Diarrhea  {Concluded) 163 

.Arsenic-poisoning.  163 — Mercurial  Poisoning.  165 — Lead-poisoning,  166 — 
Phosphorus-poisoning.  166 — .\cid-poisoning.  166 — Alkali-poisoning,  167 — 
Miscellaneous  Medicinal  and  Chemical  Poisons,  169. 

CH-APTER   X\' 

Compexsatory  Diarrhea 170 

In  Old  Age.  170 — Addison's  Disease.  171 — Diabetes,  171 — Gout.  171 — Exoph- 
thalmic Goiter.  172 — Kidney  Diseases,  172 — ^Bums,  173. 

CHAPTER   XVI 

Exteritis,   Colitis,   Exterocolitis    (Nox-specific    (?)   Ixtestix.al   C.at.arbh), 

Di-arrhea  IX 174 

Definition,  174 — General  Remarks,  174 — Etiolog>-,  176 — Pathologj-,  181. 

CBL\PTER  X\TI 

Exteritis.    Colitis.    Enterocolitis    (Xox-spectfic    (?)    Ixtestixal    C.\t.\rrh), 

Diarrhea  ix  (Continued) 186 

S\Tnptoms.  1S6 — Diagnosis,  iqo. 

CHAPTER   XVIII 

Exteritis,    Colitis.   Exterocolitis    (Xox-speclfic    (?)    Ixtestixal   Catarrh), 

Diarrhea  ix  (Concluded) 200 

Treatment,  200 — Prognosis,  209. 


CONTENTS  13 

CHAPTER   XIX 

Page 
Tubercular    Enteritis,    Colitis,    and    Enterocolitis    (Intestinal   Tubercu- 
losis), Diarrhea  in 211 

General  Remarks,  211 — Etiology,  213. 

CHAPTER   XX 

Tubercular    Enteritis,    Colitis,    and    Enterocolitis    (Intestinal   Tubercu- 
losis), Diarrhea  in  (Conlinucd) 219 

Classification,  219 — Pathology,  220. 

CHAPTER   XXI 

Tubercular   Enteritis,    Colitis,    and   Enterocolitis    (Intestinal   Tubercu- 
losis), Diarrhea  in  {Continued) 240 

Symptoms,  240 — Complications,  240 — Sequela;,  240. 

CHAPTER   XXII 

Tubercular   Enteritis,    Colitis,    ant)    Enterocolitis    (Intestinal   Tubercu- 
losis), Diarrhea  in  {Conlinucd) 255 

Diagnosis,  255. 

CHAPTER   XXIII 

Tubercular   Enteritis,    Colitis,    and    Enterocolitis    (Intestinal   Tubercu- 
losis), Diarrhea  in  {Continued) 266 

Treatment,  266 — Prophylactic  Measures,  267 — Dieting,  270 — Medical  Treat- 
ment, 271 — Irrigating  Treatment,  278 — Serum  Treatment,  282. 

CHAPTER   XXIV 

Tubercular    Enteritis,    Colitis,    ant)    Enterocolitis    (Intestinal   Tubercu- 
losis), Diarrhea  in  {Concluded) 285 

Surgical  Treatment,  285. 

CHAPTER   XXV 

Syphilitic  Enteritis,  Colitis,  and  Enterocolitis  (Intestinal  Syphilis),  Diar- 
rhea in  294 

General  Remarks,  294 — Etiology,  296 — Pathology,  297. 

CHAPTER   XXVI 

Syphilitic  Enteritis,  Colitis,  and  Enterocolitis  (Intestinal  Syphilis),  Diar- 
rhea IN  {Continued) 304 

Symptoms,  304 — Diagnosis,  307 — Prognosis,  311. 

CHAPTER   XXVII 

Syphilitic  Enteritis,  Colitis,  ant)  Enterocolitis  (Intestinal  Syphilis),  Diar- 
rhea IN  {Concluded) 313 

Medicinal  Treatment,  313 — Salvarsan,  314 — Surgical  Treatment,  318. 

CHAPTER  XXVIII 

Entamebic  Colitis  (Entamebiasis,  Entamebic  Dysentery),  Diarrhea  in 321 

Definition,  321 — General  Remarks,  321 — History,  323 — Etiology,  326 — Geo- 
graphic Distribution,  330 — Cultivation,  331 — Classification,  2>2>2 — Morphol- 
ogy, 336 — Reproduction,  339. 


14  CONTENTS 

CH.\PTER   XXIX 

Page 
ExT.\MEBic  Colitis  (Extameblvsis,  Extamebic  Dysextery),  Dl\rrhea  ix  (Con- 
tinued)    341 

Pathologj-  (Including  Tropical  Liver  Abscess;.  341. 

CH.\PTER   XXX 

Extamebic  Colitis  (Extameblasis,  Extamebic  Dysextery),  Dlarkhea  ix  (Con- 
tinued)    356 

S>Tnptom5,  356 — Complications,  361 — Hepatic  Entamebic  (Tropical)  Abscess, 
364- 

CH.APTER  XXXI 

Extamebic  Colitis  (Extamebl\sis,  Extamebic  Dysextery),  Dlarrhea  ix  (Con- 
tinued)    370 

Diagnosis,  370 — Prognosis,  374. 

CHAPTER   XXXII 

Extamebic  Colitis  (Extamebl\sis,  Extamebic  Dysextery),  Dlarrhea  ix  (Con- 
cluded)    376 

Prophylactic  Treatment.  376 — Supportive  Treatment.  377 — Diet,  377 — Z^Iedi- 
cal  Treatment,  379 — Local  Treatment,  383 — Surgical  Treatment,  389 — Treat- 
ment of  Hepatic  Abscess.  392. 

CH.\PTER   XXXni 
Baciixary  Colitis  (Bactllary  Dysextery.  AsYxt::^!  Dysextery),  Dl\rrhea  ix.  .  393 

CIL\PTER  XXXIV 

Bacillary  Colitis  (Bacill-ary  Dysextery,  Asyxum  Dysextery),  Dlarrhea  ix 

(Continued) 400 

Pathology-,  400. 

CHAPTER   XXX\' 

Bacillary  Colitis  (Bacillary  Dysextery,  Asyxxtu  Dysextery;.  Dlarrhea  ix 

(Continued) 407 

Symptoms,  407 — ^Diagnosis,  400. 

CH.APTER   XXXM 

Bacillary  Colitis  (B.\cillary  Dysentery,  Asyxeti  Dysextery),  Dlarrhea  ix 

(Concluded) 413 

Prophylactic  Treatment.  413 — iledical  Treatment,  414 — Serum  and  Vaccine 
Treatment.  416 — Irrigating  and  Local  Treatment.  418 — Surgical  Treatment, 
420. 

CH.APTER  XXX\'II 

Heimexthic  Colitis  (Par-Asitic  Counns),  Helmix-thl\sis,  Helmtn'thic  Dysen- 
tery, Dlarrhea  ix 422 

Cestodes  (^Tapeworms).  423 — Nematodes  (Round  or  Unsegmented  Worms), 
427 — Trichrniasis.  430 — .\scaria5i5.  431 — Ox>-uriasis,  433 — Trichuriasis.  435 — 
StrongY-loidosis,  436 — Trematodes  (Fluke- worms),  437 — Schbtosomiasis,  437. 

CHAPTER   XXX\TII 

Protozoal  (Parasitic)  Colitis  (Protozo.al  Dysextery).  Dla.rrhea  ix 444 

Ameba  and  Entamebae.  444 — Flagellates.  444 — Ciliates,  446 — Coccidia.  457. 


CONTENTS  15 

CHAPTER   XXXIX 

Page 
Gonorrheal  Colitis  and  Procthts  (Intestinal  Gonorrhea),  Diarrhea  in...  458 

CHAPTER   XL 

Myxorrhea  Coli,  Myxorrhea  Membranacea,  Myxorrhea  Colica,  Diarrhea  in  460 
History,  460 — I^tiologj',  460 — Pathology,  465 — Symptoms,  465 — Diagnosis,  466 
— Treatment,  46O — Prognosis,  469. 

CHAPTER   XLI 

Intestinal  Irrigation  (Enteroclysis);  Enemata  in  the  Treatment  of  Diar- 
liHEAL,  Inflammatory,  and  Parasitic  Diseases  of  the  C^astro-intestinal 

Tract 47° 

Irrigants,  473 — Technic  of  Bowel  Irrigation,  480. 

CHAPTER   XLII 

Obstructive  (Mechanic,  Surgical)  Diarrhea 488 

General  Remarks,  488 — Etiology,  490. 

CHAPTER   XLIII 

Obstructive  (Mechanic,  Surgical)  Diarrhea  {Continued) 496 

Symptoms,  496. 

CHAPTER   XLIV 

Obstructive  (Mechanic,  Surgical)  Diarrhea  {Conlinucd) 504 

Diagnosis,  504. 

CHAPTER   XLV 

Obstructive  (Mechanic,  Surgical)  Diarrhea  {Concluded) 510 

Non-operative  Treatment,  510 — Surgical  Treatment,  511. 

CHAPTER   XLVI 

Post-oper.\tive  Diarrhea 519 

Etiology  and  Pathology,  519 — Symptoms  and  Diagnosis,  522 — Treatment,  523. 

CHAPTER  XLVH 

Mesenteric  Embolism  and  Thrombosis  (Intestinal  Infection),  Diarrhea  in   526 
Etiology  and  Pathology,  526 — Symptoms  and  Diagnosis,  527— Prognosis,  528 — 
Treatment,  528. 

CHAPTER   XLVIII 
Formulary 529 

CHAPTER   XLIX 

Surgical  Treatment  of  Diarrheal,  Inflammatory,  Obstructive,  and  Par.\- 

siTic  Diseases  of  the  Gastro-intestinal  Tract 542 

General  Remarks,  542 — Preparation  of  Patient,  543. 

CHAPTER   L 

Surgical  Treatment  of  Diarrheal,  Inflammatory,  Obstructive,  and  Para- 
sitic Diseases  of  the  Gastro-intestinal  Tract  {Continued) 545 

Historic  Note,  545 — General  Remarks,  546 — Appendicocecostomy,  551 — 
Enterostomy,  552 — Colostomy,  552 — Results  of  Through-and-through  Irri- 
gating Treatment  following  Appendicostomy  and  Cecostomy,  552 — Technic 
of  Cecostomy,  554. 


I 6  CONTENTS 

CHAPTKR   LI 

Page 
Surgical  Treatment  of  Diarrheal,  Inflammatory,  Obstructive,  and  Para- 
sitic Diseases  of  the  Gastro-intestinal  Tract  {Continued) 556 

Technic  of  Gant's  Enterocecostomy  (Cecostomy),  Appendicostomy,  Appendico- 
cecostomy,  and  Appendico-enterocecostomy,  556. 

CHAPTER   LII 

Surgical  Treatment  of  Diarrheal,  Inflammatory,  Obstructive,  and  Para- 
sitic Diseases  of  the  Gastro-intestinal  Tract  {Concluded) 574 

Technic   of   Enterostomy,   Colostomy,   Enterectomy,    Cecectomy,    Colectomy, 
Sigmoidectomy,  Proctectomj',  574. 

Int)EX 589 


CHAPTER    I 

INTRODUCTION  AND  CLASSIFICATION 

Introduction. — Diarrhea  is  a  broad  subject,  and  one  which  should 
interest  aUke  physicians  and  surgeons,  because  the  services  of  one  or 
both  are  often  recjuired  to  reHeve  or  permanently  cure  patients  afflicted 
with  it.  Although  less  frequently  than  constipation  and  intestinal 
stasis,  diarrhea  is  met  with  quite  often,  and  when  persistent  usually 
induces  more  suffering,  digestive  disturbances,  loss  of  weight,  and 
impairment  to  metabolism  than  constipation. 

Diarrhea  is  a  symptom  characterized  by  frequent  and  fluid  evacu- 
ations. This  definition  is  not  entirely  satisfactory,  because  by  some, 
fragmentary  constipation  is  classed  as  a  diarrhea  because  the  patient 
has  several  daily  movements;  but  this  is  a  mistake,  since  the  feces 
are  semisolid  or  formed,  and  are  cut  off  and  ejected  in  small  pieces 
in  consequence  of  the  irritable  state  of  the  levator  ani  and  sphincter 
muscles.  Again,  some  patients  regularly  have  two  or  three  daily 
evacuations,  and  the  stools  of  others  persistently  remain  mushy  or  semi- 
solid, and  yet  health  is  maintained;  consequently,  such  individuals 
do  not  suffer  from  diarrhea,  though  they  or  their  physicians  think  they 
do,  and  believe  something  should  be  done  to  diminish  the  evacuations 
or  cause  them  to  become  formed.  When,  how'ever,  a  patient  has 
two  or  more  movements  daily  containing  mucus,  pus,  or  blood,  a 
diagnosis  of  diarrhea  is  justifiable  because  evidently  there  is  some 
pathologic  change  going  on  in  the  intestine  which  is  causing  abnormal 
peristalsis,  the  hypersecretion  of  mucus,  or  transudation  of  fluid  into 
the  bowel. 

Owing  to  its  many  and  varied  types,  it  is  necessary  that  prac- 
titioners who  treat  diarrhea  should  be  adepts  in  the  diagnosis  and 
treatment  of  gastro-intestinal  and  allied  diseases. 

Diarrhea  is  a  common  topic  in  current  literature  and  medical 
societies,  but  the  etiology,  pathology,  diagnosis,  and  especially  the 
treatment  of  this  condition  are  not  understood;  or,  if  they  are,  phys- 
icians generally  do  not  take  the  pains  or  time  to  institute  or  carry  out 
a  successful  line  of  treatment.  This  has  been  demonstrated  many 
times  in  the  author's  pri\ale  hospital  and  clinic  work,  where  patients 
who  suffered  from  chronic  diarrhea  for  years  in  spite  of  constant  medi- 
cal treatment  and  dieting  have  been  speedily  cured  by  the  operatixe 
or  other  measures  outlined  in  the  following  pages.  Failure  in  many 
instances  is  due  to  the  attendant  in  charge  prescribing  something 
which  will  quickly  diminish  or  check  the  evacuations  or  lessen  their 
fluidity,  but  does  nothing  to  mitigate  or  remove  the  cause  of  the  fre- 
(luent  evacuations. 

2  17 


1 8  INTRODUCTION    ANT)    CLASSIFICATION 

WTiile  physicians  are  prone  to  look  upon  frequent  loose  move- 
ments as  a  manifestation  of  some  other  affection,  the  patient  does 
not.  and  seeks  treatment  for  the  diarrhea  which  he  considers  respon- 
sible for  his  pain,  gas  disturbances,  frequent  evacuations,  loss  of 
appetite,  diminished  weight,  detention  from  business,  inability  to 
eat  what  he  chooses  or  participate  in  the  pleasures  of  life  because  of 
the  frequent  visits  he  must  necessarily  make  to  the  toilet,  and  extra 
outlay  for  medicines  and  doctors'  bills. 

Prolonged  diarrhea,  through  loss  of  sleep,  drain  upon  the  system, 
worry,  digestive  disturbances,  and  auto-intoxication  (which  frequently 
accompanies  it  and  tends  to  the  production  of  other  circulator\'  de- 
fects), lowers  the  vitalits^  and  bodily  resistance,  and  altogether  makes 
the  patient  an  easy  prey  to  microbes,  and  is  often  the  direct  source  of 
pathologic  changes  within  the  gut.  in  close  proximity  to  it,  and  in  dis- 
tant parts  because  the  irritating  fluid  discharges  ser\'e  to  erode  or  break 
the  continuity  of  the  intestinal  mucosa,  permit  specific  and  non- 
specific bacteria  to  enter  the  circulation  and  be  carried  to  remote 
parts,  where  they  cause  trouble,  or  penetrate  deeply  into  or  through 
the  intestinal  wall  with  the  resultant  production  of  deep-seated  mixed 
infection,  ulcers,  abscesses,  fistulae,  pyemia,  peritonitis,  septic  pneu- 
monia, or  other  serious  complications. 

The  profession  is  usually  prone  to  regard  diarrhea  as  being  due 
to  a  single  cause  when  its  etiolog>'  is  complex  and  embraces  causes 
which  are  emotional,  due  to  local  disease  in  the  gastro-intestinal 
tract,  and  those  of  a  more  general  character;  but  it  matters  not 
whether  the  disturbing  element  belongs  to  the  first,  second,  or 
third  group,  for  it  induces  frequent  evacuations  by  augmenting  the 
gastro-intestinal  secretions,  stimulating  frequent  and  prolonged 
peristalsis,  diminishing  or  blocking  the  bowel  lumen,  so  that  there  is 
only  room  for  fluid  feces  to  dribble  past  the  obstructed  point,  all  of 
which  have  received  careful  consideration  in  their  proper  place. 

Loose  movements,  except  those  consequent  upon  intestinal  ob- 
struction, are.  as  a  rule,  secondary-  to  stimuli  which  directly  or  indi- 
rectly influence  the  bowel.  Such  stimuli  may  lead  to  diarrhea  by 
causing  hyperperistalsis.  the  transudation  of  fluid  from  the  blood 
through  the  bowel  wall  into  the  intestinal  lumen,  and  hypersecretion 
of  mucus. 

Stimuli  responsible  for  diarrhea  may  be  induced  by  psychic  emo- 
tions, disease  of  the  brain,  cord,  general  or  local  nerve  mechanism, 
inflammation,  ulceration,  neoplasms,  strictures  or  foreign  bodies  in 
the  intestine,  or  lesions  affecting  it  from  without,  or  anything  which 
irritates  the  intestinal  ner\-e-ganglia. 

Occasionally,  multiple  or  widely  varying  stimuli  work  simul- 
taneously, so  that  a  vicious  circle  is  established,  under  which  circum- 
stances there  is  exaggerated  intestinal  motility,  and  the  patient 
suffers  deplorably  from  diarrhea  extremely  difficult  to  relieve  or  cure. 

Sometimes  the  disturbing  factors  causing  diarrhea  are  located  in 
the  stomach  or  small  intestine,  and  the  chyme  is  improperly  digested 


INTRODUCTION  I9 

or  rushed  throui^h  the  gastro-intcslinal  tract  before  its  watery  con- 
stituent can  be  absorbed.  Again,  frequent  and  fluid  evacuations 
are  secondary  to  inflammatory  and  ulcerative  lesions  which  impair 
the  absorptive  power  of  the  colonic  mucosa,  and,  as  a  result,  the 
fluid  content  of  the  bowel  which  should  reach  the  circulation  is 
evacuated.  ^ 

Because  of  the  many  and  varied  types  of  diarrhea  it  is  impossible  / 
to  formulate  a  routine  treatment  which  will  meet  the  conditions  in 
different  cases,   and  diarrhea  requires  distincti\e  consideration  and 
treatment  in  each  case.    . 

Those  afflicted  with  this  complaint  wh(j  come  to  the  author  are 
asked  the  questions,  "Are  you  seeking  temporary  relief^''  or  "Do  you 
desire  that  I  shall  institute  a  course  of  treatment  which  will  have  for  its 
object  a  permanent  cure?''  because  the  therapeutic  measures  to  be 
instituted  hinge  upon  the  patient's  decision. 

One  can,  by  controlling  the  diet  and  administering  medicines 
which  contain  astringents,  antiseptics,  opiates,  etc.,  make  the  patient 
more  comfortable  and  reduce  the  freciuency  of  the  stools,  but,  when  a 
cure  is  insisted  upon,  the  symptomatic  treatment  (except  in  urgent 
cases)  should  be  discarded  in  favor  of  surgical  or  other  therapeutic 
measures  which  tend  to  eliminate  one  or  all  the  causes — local,  general, 
nervous,  or  psychic — responsible  for  the  diarrhea. 

Sufferers  from  chronic  diarrhea  are  told,  when  beginning  treat- 
ment, that  it  may  require  weeks  or  months  to  effect  a  cure,  and  that, 
to  obtain  the  best  results,  it  is  necessary  for  them  to  make  a  business 
of  getting  well — carry  out  instructions   and    come  for  treatment  as    i 
often  and  long  as  necessary.  ^ 

The  author  speaks  from  experience  when  he  says  that  a  great  deal 
can  be  accomplished  in  the  handling  of  this  class  of  cases  by  continu- 
ous treatment,  and  that  the  results  are  unsatisfactory  when  it  is 
interrupted  by  patients  who  spasmodically  apply  for  a  prescription, 
irrigation,  etc.,  or  neglect  the  treatments  because  they  are  indifferent, 
busy,  or  wish  to  save  a  fee. 

Frequent  loose  movements  are  regarded  as  a  symptom  of  disease, 
and  the  physician  is  prone  to  concentrate  his  efforts  exclusively  against 
the  latter,  while  he  does  little  or  nothing  for  the  former,  taking  it  for 
granted  that  the  frequent  evacuations  will  cease  when  the  affection 
responsible  for  diarrhea  has  been  cured,  a  procedure  to  be  commended 
in  some  and  condemned  in  other  instances.  Practitioners  often  fail 
in  reliexing  diarrhea  or  curing  the  disease  back  of  it  because  they 
attribute  the  frequent  evacuations  to  pathologic  changes  in  the  gastro- 
intestinal tract,  and  fail  to  realize  the  frequency  with  which  diarrhea 
is  caused  by  emotional  and  reflex  disturbances,  outside  toxemias 
(which  act  upon  the  intestine),  nervous  affections,  abnormalities  of 
the  circulating  media,  diseased  organs  or  structures  adjacent  to  or 
remote  from  the  bowel,  and  numerous  other  factors  elsewhere  dis- 
cussed. Many  physicians  in  the  past  have  considered,  and  some  at 
present  regard,  diarrhea  as  a  medical  disease,  and  treat  it  accordingly, 


20  INTRODUCTION    AND    CLASSIFICATION 

when  frequently  the  condition  is  surgical  and  cannot  be  corrected 
except  through  recourse  to  the  operations  described  in  the  text. 
This  is  evidenced  by  the  author's  large  experience,  which  has  demon- 
strated that  in  many  instances  diarrhea  can  be  cured  by  surgical  in- 
tersention  after  it  has  been  unsuccessfully  treated  for  years  by  medi- 
cine and  other  non-surgical  measures. 

Medicine  can  be  relied  upon  to  lessen  pain,  diminish  frequency  of 
evacuations,  and.  in  rare  instances,  to  affect  a  cure  in  acute  and 
chronic  diarrhea,  but.  as  a  general  rule,  it  is  not  dependable  when  it 
comes  to  permanently  correcting  or  removing  the  cause  of  the  trouble. 
Too  often  medicine  is  prescribed  with  the  object  of  affording  immedi- 
ate relief,  and  not  with  the  idea  that  it  will  permanently  benefit  the 
patient,  by  busy,  careless,  or  ignorant  practitioners,  who  do  not  tn,', 
or  fail  to  find,  the  disturbing  factors  responsible  for  the  diarrhea,  and. 
as  a  result,  these  sufferers  are  usually  dosed  for  weeks,  months,  or 
years  with  morphin,  opium,  bismuth,  tannic  acid,  chalk,  salol,  and 
like  remedies  which  lessen  the  movements  while  the  patient  is  under 
their  continued  influence,  but  which  othenvise  do  no  good,  since  the 
diarrhea  becomes  equally  or  more  marked  as  soon  as  drugs  are  with- 
drawn. 

The  indiscriminate  prescribing  of  medicines  for  this  affection  is  to 
be  condemned,  because  they  frequently  destroy  the  appetite,  encour- 
age insomnia,  interfere  with  digestion,  are  nauseating,  cause  subse- 
quent headaches,  irritate  the  gastro-intestinal  mucosa,  lead  to  the 
formation  of  enteroliths  (bismuth  and  salolj,  which  cause  obstruction, 
and  patients  often  become  drug  Imhitucs. 

Recently  great  advance  has  been  made  in  the  prophylactic,  psychic, 
and  dietetic  treatment  of  diarrhea  and  allied  conditions,  alone  or  in 
conjunction  with  physical  therapeutic  measures  (massage,  electricity, 
vibration,  hydrotherapy,  concentrated  light,  etc.),  irrigation,  entero- 
clysis,  where  the  fluid  is  introduced  through  the  anus  or  an  arti- 
ficial opening  made  in  the  small  intestine  (enterostomy),  appendix 
(appendicostomy).  cecum  (cecostomy).  or  colon  (colostomy),  or  the 
surgical  procedures  elsewhere  described. 

Because  of  the  surprisingly  good  permanent  results  obtained  by  the 
author  in  the  surgical  treatment  of  diarrheal  affections,  and  the  fre- 
quent failures  and  complications  which  follow  the  pernicious  custom 
of  uni^  ersally  administering  medicine  by  mouth,  he  has,  when  feasible, 
recommended  the  former  to  the  exclusion  of  the  latter  plan,  and,  as 
a  rule,  has  not  prescribed  drugs  except  when  necessan.-  to  immedi- 
ately relieve  symptoms  which  have  suddenh-  become  annoying  or 
dangerous. 

Direct  bowel  treatment  is  not  employed  as  frequently  as  it  should 
be — certainly  the  author's  experience  warrants  him  in  the  belief  that 
more  can  be  accomplished  in  the  treatment  of  chronic  loose  move- 
ments consequent  upon  non-specific  and  specific  inflammaton,-  dis- 
eases of  the  intestine  by  irrigation  and  topical  applications  than  by  hav- 
ing the  patients  diet  and  drug  themselves. 


CLASSIFICATION  21 

Inflamed  and  ulcerated  areas  in  the  intestinal  mucosa  readily 
respond  to  direct  treatment  after  measures  usually  instituted  for 
their  cure  have  failed  to  heal  them.  Sometimes  the  colon  can  be 
treated  by  medicated  irrigations  introduced  by  way  of  the  anus,  but 
when,  for  any  reason,  the  various  segments  of  the  bowel  cannot  be 
reached,  or  the  procedure  is  not  feasible,  appendicostomy,  cecostomy, 
or  the  author's  enterocecostomy  are  indicated,  so  that  through-and- 
throiigh  irrigation  meiy  be  instituted. 

Barring  obstructive,  the  vast  maj(^rit\-  of  diarrheas  character- 
ized by  the  presence  of  mucus,  pus,  and  blood  in  the  stools  can  be 
quickly  and  permanently  relieved  in  this  way. 

Mechanic,  obstructive,  or  surgical  diarrhea  is  seldom  mentioned  in 
niedical  lectures  or  articles;  yet  it  occurs  frequently,  and  if  i)hysicians 
appreciated  its  importance,  and  the  ease  with  which  it  can  be  relieved 
or  cured  by  operation,  many  patients  would  be  saved  who  now  die 
when  treated  in  the  ordinary  wa>'. 

Obstructive  diarrhea  is  fairly  common,  and  may  be  produced  by 
many  pathologic  lesions,  foreign  bodies,  or  fecal  impaction  which 
block  the  bowel  and  retain  solid,  but  allow  the  fluid  feces  to  be 
frequently  evacuated.  This  type  of  loose  movements  is  often 
overlooked,  and  opium  and  bismuth  are  prescribed  to  diminish  the 
stools,  remedies  which  tend  to  aggravate  rather  than  relieve  the 
patient's  condition. 

Surgical  intervention  is  indicated  in  the  treatment  of  chronic 
diarrhea  as  well  as  appendicitis  when  it  is  induced  by  inflammatory, 
ulcerative,  or  obstructing  lesions  which  do  not  respond  to  ordinary 
measures. 

Fragmentary  constipation  is  sometimes  mistaken  and  treated  for 
diarrhea  because  the  patient  goes  to  the  toilet  frequently;  but  such 
errors  would  not  be  made  did  the  physician  regularly  examine  the 
stools,  for  in  these  cases  the  excreta  is  ejected  in  short  semisolid  or 
firm  pieces.  Since  the  fecal  bolus  is  divided  into  small  sections  through 
the  scissors-like  action  of  the  external  sphincter  or  levator  ani  muscle 
when  irritated,  or  by  O'Beirne's  sphincter  at  the  rectosigmoid  junc- 
ture, it  is  obvious  in  this  class  of  cases  that  the  therapeutic  agents 
usually  employed  in  the  treatment  of  diarrhea  only  make  matters 
worse. 

Classification. — At  first  one  might  think  diarrheas  easy  to  group, 
but  on  further  study  they  become  difificult  or  impossible  to  classify 
owing  to  their  varied  etiology,  pathology,  manifestations,  and 
association  with  dift'erent  local  and  general  diseases.  They  may, 
however,  be  etiologically  grouped  SiS  junctional  and  organic,  and  clinic- 
ally, into  the  acute  and  chronic  types. 

The  author  has  attempted  to  classify  diarrheas  etiologically  on 
pages  22  and  23,  but  he  recognizes  that  this  arrangement  is  not 
entirely  satisfactory,  since  the  causes  of  some  affections  responsible 
for  diarrhea  still  remain  undiscovered  or  in  doubt. 


22 


INTRODUCTION    AND    CLASSIFICATION 


^  {  Diarrhea 

O 
I— ( 

H 
< 


Organic  diseases: 


Amyloidosis : 

Acute  infectious 
and  contagious 
diseases : 


Miscellaneous  in- 
fectious dis- 
eases : 


Gastrogenic      ab- 
normalities: 

Enterogenic      ab- 
normalities: 

Neurogenic      dis 
turbances 

Poisons: 


Ocular. 

Buccal. 

Dental. 

Naso]  pharyngeal. 

Thyroid  gland. 

Liver. 


Pancreas. 

Kidney. 

Suprarenal. 

Genital. 

Skin. 

Bone. 


Lardaceous  degeneration  (intestinal). 


Measles. 

Varicella. 

Variola. 

Influenza. 

Cholera. 

Winter  cholera. 

Choleriform  diarrhea. 

Sepsis. 

Erysipelas. 


Scarlet  fever. 

\\'hooping-cough. 

Diphtheria. 

Pneumonia. 

Pseudodysentery. 

El  Bicho  diarrhea. 

Anthrax. 

Plague. 

Glanders. 


from  <!  Sundry  diseases:     \ 


Sundry  causes:       { 


-f 


Cochin-China  diarrhea.  Sutika. 

Sprue.  Intestinal  myiasis. 

Hill-diarrhea.  Pellagra. 

Alba  diarrhea.  Actinomycosis. 

T^^phoid,     relapsing,    yellow,    malarial, 

typhus  fevers. 
Coprostasis. 
Obesity. 
Cachexia. 
.\nemia. 

Pernicious  anemia. 
Leukemia. 
Alcoholism. 
Marasmus. 
Catharsis. 
Burns. 
Chilling. 
Old  age. 
Irregularities  in  living. 

Drinking  impure  water  and  ice-cold  beverages. 
Sun-  and  heat-strokes. 
Nocturnal,  eosinophilic,  mechanic,  and  reflex 

diarrheas. 
Achylia  gastrica.  H\'perchlorhydria. 

Malignancy.  INIotor  insufficiency. 

.\tony. 

L^nbalanced  succus  entericus. 
Duodenal  ulcer. 
Hypermotility. 
Psychic. 
Reflex. 

Diseases  and  injuries  of  the  nervous  system. 
Food — Canned  goods.     Bacterial  (ptomain). 
Medicinal.  Chemical. 


and 


Arteriosclerosis. 

Enteritis  crouposa  ne- 
crotica. 

Gout. 

^Methemoglobinemia. 

Scur\->'. 

Cerebrospinal  meningi- 
tis. 

H\'pod}Tiamia  cordis. 

Agoraphobia. 

Sitophobia. 


In  his  classification  the  author  has  endeavored  to  get  away  from 
the  term  "dysentery,"  which  is  not  a  disease,  but  a  symptom-complex, 
represented  by  abdominal  pain,  diarrhea,  tenesmus,  mucus  and  hlood 
in  the  stools,  manifestations  common  to  all  inflammatory  afi'ections 
of  the  colon  complicated  by  ulceration ;  and  to  this  end  he  has  employed 
the  caption  colitis  plus  the  prefix  of  the  etiologic  factor  back  of  the 
inflammatory  process  to  designate  the  disease — viz.,  non-specific 
{catarrhal),  entamehic,  hacillary,  helminthic,  protozoal,  tubercular, 
syphilitic,  gonorrheal,  and  malignant  colitis. 

With  this  arrangement  the  caption  employed  indicates  the  etio- 


CLASSIFICATION 


23 


f  Compensatory  action  of  the  system, 
f  Non-specific  (?)  (Catarrhal). 
I  f  Tubercular. 

Syphilitic. 

Gonorrheal. 


Colitis:  i 


Specific : 


\l 


Protozoal: 


Bacillary: 


Helminthic 


Caused  by: 
f  Entamebae. 
1  Flagellates. 
,  Ciliates. 
[  Coccidia. 
f  Shiga  bacilli. 
!  Strong  bacilli. 
•^  Uuval  bacilli. 
I  Flexner-Harris  bacilli. 
(^  Hiss  and  Russel  bacilli. 
(  Cestodes. 


Nematodes. 
Trematodes. 


,,  ,  ,.    f  Myxorrhea  membranacea. 

Myxorrhea  coli:  |  ..ij.^orrhea  colica. 

f  Congenital  deformities. 


i  Diarrhea  from  < 


Intestinal  obstruction  (intesti- 
nal stasis,  surgical  diarrheas) : 


Postoperative  causes. 


External  pressure. 

Strictures. 

Neoplasms. 

Foreign  bodies. 

Intestinal  calculi. 

Fecal  impaction. 

Adhesions. 

Angulations. 

Flexures. 

PericoUtis. 

Sigmoiditis. 

Perisigmoiditis. 

Mesosigmoiditis. 

Diverticulitis. 
]  Peridiverticulitis. 
I  Rectocele. 

Postoperative  sequelae. 
I  Sacculation. 
I  Abnormal  mesentery. 
I  \'olvulus. 

Kinks. 
I  Hernia. 
I  Invagination. 
I  Rectal  procidentia. 

Enteroptosis. 
I  Paralytic  ileus. 

Dilatation  of  the  colon. 
I  Enterospasm. 
(^Intestinal  parasites. 


logic  factor  behind  the  inflammation,  pathologic  changes  which  charac- 
terized it,  plan  of  treatment  to  be  adopted,  and  leaves  careless  phys- 
icians without  an  excuse  for  diagnosing  as  dysentery  and  handling  in 
a  routine  way  all  patients  who  complain  of  abdominal  pain,  tenesmus, 
diarrhea,  and  mucus  and  blood  in  the  stools. 


CHAPTER    II 

EXAMINATION   AND  DIAGNOSIS 

Diarrhea  is  easy  to  diagnose  because  the  patient  will  voluntarily 
or  upon  questioning  say  that  the  stools  are  more  frequent  and  loose 
than  they  should  be.  It  is,  however,  very  difficult  in  many  instances 
to  ascertain  what  is  the  trouble.  This  is  not  to  be  wondered  at 
when  one  sees  the  varied  types  of  diarrhea  and  the  almost  innum- 
erable functional  and  organic  disturbances  and  other  factors  which 
may  induce  loose  movements. 

Usually  there  will  be  found  a  chief  cause  for  the  disturbance,  but 
often  several  etiologic  factors  are  present,  any  one  of  which  is  suffi- 
cient to  incite  frequent  or  fluid  evacuations,  and  must  be  considered 
when  outlining  the  treatment.  Occasionally  diarrhea  arises  from  defects 
in  the  bowel  the  result  of  diseases  already  cured,  but  which  have  left 
their  sequeUe  to  continue  the  loose  movements  until  they  are  relieved 
or  corrected.  In  order  to  make  a  rational  diagnosis  in  this  class  of 
cases  a  routine  method  of  examination  should  be  followed.  This 
consists  in  obtaining  a  brief  but  intelligent  history  of  the  case  from  its 
beginning,  along  with  the  symptoms  complained  of,  carefully  inspect- 
ing the  patient  from  every  standpoint:  palpating  the  spinal,  abdomi- 
nal, pelvic,  and  anorectal  regions;  percussing  the  liver,  kidneys,  pan- 
creas, spleen,  stomach,  and  intestines;  practising  succussion  over  the 
stomach  and  colon;  making  a  chemic,  macroscopic,  and  microscopic 
examination  of  the  stomach  and  intestinal  contents  independently  and 
following  test-meals;  examining  the  blood,  urine,  and  secretions;  dis- 
tending the  bowel  with  air,  gas,  or  water,  so  that  its  segments  may  be 
outlined  or  obstructions  located;  inspecting  the  rectum  and  sigmoid 
flexure  through  the  proctosigmoidoscope ;  making  a  digital  and  specular 
examination  of  the  vagina  and  anorectal  region;  taking  radiographs 
of  the  viscera  or  studying  them  through  the  fluoroscope;  and,  in  obscure 
cases,  in  examining  the  patient  while  under  ether  or  following  an 
exploratory  incision. 

History. — A  complete,  but  not  necessarily  lengthy,  history  should 
be  taken  and  recorded  in  each  case,  because  in  this  way  valuable 
information  can  often  be  obtained  which  would  lead  the  attendant  to 
suspect  the  nature  of  the  trouble.  One  should  draw  the  history  from 
the  patient  by  direct  questioning  instead  of  letting  him  tell  his  own 
story,  as  some  physicians  do,  and  in  this  way  ascertain  how  long  he 
has  been  ill,  if  the  diarrhea  was  of  sudden  onset  or  came  on  gradually, 
is  constant  or  intermittent,  slight  at  one  time  and  aggravated  at 
another,  alternates  with  constipation,  if  it  was  manifest  from  the  start 
or  secondary  to  another  ailment,  if  the  stools  are  foul  smelling  or 
24 


POSITION    OF    THE    PATIENT  2$ 

contain  blood,  pus,  or  mucus,  the  feces  are  normal  in  shape,  size,  and 
consistence,  the  abdomen  is  tender  on  pressure,  the  stools  are  pre- 
ceded, accompanied,  or  followed  by  tenesmus,  straining  or  pain,  and 
if  the  patient  suffers  from  other  manifestations  indicativ'e  of  disease 
that  would  cause  diarrhea. 

It  is  important  to  learn  from  the  patient  his  age,  occupation, 
habits,  character  of  food  he  eats,  if  he  is  dissipated  or  takes  medicine 
which  would  increase  the  frequency  and  fluidity  of  the  movements, 
and  if  he  is  afflicted  with  or  has  in  the  past  suffered  from  digestive 
disturbances,  gastritis,  enteritis,  appendicitis,  abdominal  or  pelvic 
disease,  affections  of  the  liver  or  pancreas,  gall-stones,  congenital 
deformities,  operative  sequeUe,  or  other  local  disease  which  would 
interfere  with  digestion  or  leave  the  mucosa  irritable,  inflamed,  or 
ulcerated,  diseases  frequently  complicated  by  tumefactions,  adhesions, 
kinks,  or  stricture  which  may  induce  obstructive  diarrhea. 

One  should  also  ascertain  if  the  patient  is  paler  than  formerly, 
has  lost  weight,  has  nasal  catarrh,  bad  teeth,  furred  tongue  or  foul 


Fig.  I. — Correct  Sims'  posture  for  rectal  examination. 

breath,  disagreeable  taste  in  the  mouth,  or  suffers  from  loss  of  appetite, 
nausea,  or  vomiting.  Finally,  it  is  well  to  discover  if  the  patient 
swallows  with  difficulty  (esophageal  stenosis  or  cardiospasm)  or 
suffers  from  localized  abdominal  pain  and  tenderness  on  pressure, 
manifestations  which  indicate  the  presence  of  an  ulcer,  stricture, 
tumor,  or  foreign  body  in  the  stomach  or  intestine,  which  might  be 
responsible  for  the  frequent  and  loose  evacuations.  When  the  anam- 
nesis is  concluded  the  patient  should  be  systematically  examined  by 
the  diagnostic  physical  measures — inspection,  succussion  (clapote- 
ment),  auscultation,  percussion,  palpation,  and  inflation — and  with 
esophagoscope,  gastroscope,  proctoscope,  sigmoidoscope,  and  rectal 
speculum,  acccjrding  t(j  indications. 

Position  of  the  Patient.- — Patients  who  suffer  from  obscure  diar- 
rhea should  be  examined  while  standing,  or  on  a  table  while  resting 
upon  the  sides  or  back,  with  the  limbs  flexed  and  extended,  during 
deep  inspirations  and  expirations,  and  the  posture  should  be  changed 
during  the  examination,  that  any  change  in  position  of  the  hollow 


26  EXAMINATION    AND    DIAGNOSIS 

viscera,  solid  organ,  or  tumors  may  be  noted.  The  Sims'  knee;,-chest 
and  inverted  postures  are  required  for  a  complete  digital,  proctoscopic, 
and  sigmoidoscopic  examination  of  the  rectum  and  sigmoid  fiexure 
(Figs.  I  and  5).  By  examining  the  patient  while  standing  erect  one 
can  observe  bulging  from  tumors,  a  pendulous  belly  due  to  enteroptosis, 
determine  if  the  abdominal  viscera,  organs,  or  neoplasms  previously 
felt  have  descended  to  a  lower  level,  and,  by  introducing  the  linger 
into  the  rectum  and  having  the  patient  strain,  growths  and  other 
lesions  not  discoverable  in  other  postures  can  be  reached  with  the 
finger. 

Inspection. — General  inspection  of  the  patient  is  a  valuable  aid 
in  the  diagnosis  of  diarrhea  and  allied  ailments,  because  in  this  way 
one  readily  determines  if  the  patient  is  cyanotic,  jaundiced,  anemic, 
pale,  cachectic,  has  an  unhealthy  color,  a  facial  expression  of  anxiety, 
is  debilitated,  emaciated,  has  flabby  muscles,  hernia,  congestion  of 
the  superficial  veins  of  the  abdomen,  and  if  the  abdominal  wall  is  well 
developed,  thin,  flabby,  or  visibly  protrudes. 

A  study  of  the  abdomen  in  diarrheal  subjects  enables  one  to  note 
if  it  is  distended,  bulges  more  prominently  in  one  part  than  another, 
is  depressed,  pendulous,  or  overhanging.  Irregularities  which  indi- 
cate contracting  adhesions,  an  enlarged  viscus,  tumor,  fecal  impaction, 
enteroptosis  or  obstruction,  and  gas  distention  above  the  block  in- 
duced by  intestinal  stenosis,  angulation,  volvulus  or  extra-intestinal 
pressure,  conditions  which  frequently  cause  irritative  or  obstructive 
diarrheas,  are  noticeable. 

A  careful  examination  of  the  mouth  will  quickly  show  if  the  tongue 
is  coated,  the  teeth  are  bad,  or  if  ulcers  are  present,  which  would  indi- 
cate syphilis  or  other  types  of  infection,  because  one  or  all  may  at 
times  induce  gastro-intestinal  disturbances,  and  inspection  of  the  nose 
and  pharynx  will  reveal  if  there  is  nasal  catarrh  or  disease  of  the 
tonsils  or  throat  which  might  have  a  bearing  upon  the  case. 

The  rectum  and  sigmoid  can  be  viewed  through  the  proctosigmoid- 
oscope,  and  ulcers,  strictures,  cancers,  polypi,  hemorrhoids,  and  other 
aftections  can  be  quickly  located. 

Succussion  or  clapotement  is  useless,  except  in  so  far  as  it  relates 
to  the  stomach  and  colon.  When  the  abdomen  is  thin,  and  these 
organs  are  relaxed  and  contain  a  fair  amount  of  fluid,  a  splashiug 
sound  may  occasionally  be  induced  by  repeatedly  and  rapidly  strik- 
ing the  abdomen  with  the  tips  of  the  fingers  and  an  idea  obtained  as 
to  their  position.  From  what  has  been  said,  it  may  be  inferred  that 
succussion  is  a  doubtful  diagnostic  aid,  and  is  useful  only  in  determin- 
ing limitations  of  the  stomach  and  large  bowel. 

Auscultation  may  be  relied  upon  for  detecting  phthisis,  bronchi- 
tis, pleurisy,  heart  murmurs,  meteorism  and  abdominal  gurgling 
sounds,  and  delayed  entrance  of  the  food  into  the  stomach  in  esopha- 
geal stenosis,  but,  except  when  these  conditions  in  some  way  influence 
the  movements,  auscultation  plays  an  unimportant  part  in  the  diag- 
nosis of  diarrhea. 


1 


PALPATION'  27 

Percussion  is  often  lu'li)lul  in  locating  tumors,  fecal  impaction, 
and  other  pathologic  conditions  which  interfere  with  the  fecal 
current  and  cause  obstructive  diarrhea.  By  percussing  the  abdomen 
one  can  sometimes  determine  if  the  intestine,  especially  the  colon, 
and  other  abdominal  and  pelvic  organs  are  diseased,  enlarged,  or 
displaced,  and  whether  the  bowel  is  empty  or  is  partially  or  com- 
pletely filled  with  gas  and  feces.  Percussion  over  an  enlarged  liver, 
tumor,  or  fecal  mass  gives  a  flat  note,  while  normally  over  the  intes- 
tine the  sound  has  a  higher  pitch.  In  cases  of  enteroptosis  the  degree 
of  displacement  and  dilatation  can  easily  be  ascertained  by  carefully 
percussing  along  the  course  of  the  colon,  first  in  the  empty  state,  and 
then  after  it  has  been  distended  with  gas  or  water.  Again,  this 
diagnostic  adju\'ant  is  useful  for  locating  twists,  angulations,  stric- 
tures, and  other  obstructive  lesions  of  the  intestine  in  conjunction 
with  inflation.  Following  artificial  distention  with  air  or  gas,  the 
part  of  bowel  below  the  block  gi\es  a  \ery  high  note  on  percussion 
and  makes  the  abdomen  bulge  outward,  while  the  empty  segment 
above  gives  a  low  note  and  the  abdominal  wall  over  it  looks  sunken 
in.  Sometimes  one  obtains  a  high  and  at  others  a  low  note  over  a 
tumor,  a  peculiarity  accounted  for  by  the  presence  of  a  gas-filled 
piece  of  intestine  over  it  at  one  time,  while  at  another  nothing  is 
interposed  between  the  neoplasm  and  the  abdominal  wall.  Ptosis 
and  dilatation  of  the  colon  are  easily  diagnosed  following  inflation, 
because  the  outline,  size,  and  location  of  the  gut  can  be  determined 
by  percussion,  palpation,  and  by  separately  inflating  the  stomach  and 
large  bowel,  and  the  relation  of  the  organs  can  be  defined  in  colop- 
tosis,  gastroptosis,  and  splanchnoptosis. 

Palpation  is  the  most  valuable  of  the  measures  employed  in  phys- 
ical diagnosis.  Important  information  can  usually  be  obtained  in 
obscure  cases  of  diarrhea  by  first  superficially  and  then  deeply 
palpating  the  abdomen,  with  the  patient  first  in  one  position  and 
then  in  another,  and  with  his  legs  extended  or  flexed.  Superficial 
palpation  enables  one  to  detect  uneven  surfaces  of  the  skin,  enlarged 
veins,  and  character  of  the  abdominal  wall,  and  note  if  it  is  too  thin, 
fat,  rigid,  or  relaxed,  for  in  the  latter  case  it  would  not  properly  sup- 
port the  abdominal  viscera.  By  means  of  firm,  deep,  single-handed 
or  bimanual  palpation  one  can  locate  tender  and  painful  spots  and 
gas  collections,  determine  the  thickness,  size,  location,  and  sensibility 
of  the  hollow  and  solid  viscera,  and,  in  favorable  cases,  isolate  neo- 
plasms, angulations,  invaginations,  tumefactions,  intestinal  foreign 
bodies  or  hardened  fecal  accumulations  (Fig.  2),  and  also  differenti- 
ate between  fecal  and  benign  and  malignant  tumors.  Palpation  will 
reveal  that  growths  are  hard,  fixed,  and  non-indentable,  and  that 
fecal  tumors  are  of  a  doughy  consistence,  movable,  indentable,  often 
multiple,  and  slip  ov-er  the  mucosa,  in  contradistinction  to  neoplasms, 
which  are  immovable. 

In  complicated  cases  the  liver,  spleen,  pancreas,  stomach,  duodenal 
region,  colon,  sigmoid  flexure,  and  pelvic  organs  should  be  systematic- 


28 


EXAMINATION    AND    DIAGNOSIS 


ally  and  separately  palpated,  superficially  and  deeply,  and  hernial 
openings  and  lymph-nodes  should  be  carefully  examined.  Palpation 
is  not  reliable  for  determining  the  presence  of  pathologic  lesions  in 
the  small  intestine,  except  in  stricture  where  gas  accumulations  and 
active  peristalsis  limited  to  certain  segments  of  the  bowel  can  be  made 
out,  but  it  renders  valuable  aid  in  the  diagnosis  of  lesions  affecting 
the  appendix,  colon,  sigmoid  flexure,  rectum,  and  anal  perineal 
regions. 

\A'hen  used  in  conjunction  with  inflation,  palpation  is  decidedly 
useful  in  determining  the  presence  of  enterospasm,  finding  out  if 
abdominal  organs  are  abnormally  large,  hard  or  displaced,  and  for 
locating  all  varieties  of  obstruction  within  the  colon  by  examining  it 
before  and  after  its  distention  with  air,  gas,  or  water.  Lesions  and 
tumors  located  in  the  sigmoid  flexure  and  rectum  can  be  palpated, 


Fig.  2. — Showing  most  common  locations  of  fecal  impaction,  named  from  below  upward. 

when  high,  through  the  sigmoidoscope,  and,  when  low,  with  the  finger. 
When  examining  the  colon  the  hands  should  be  placed  at  a  right 
angle,  and  it  should  be  rolled  backward  and  forward  or  the  bowel 
grasped  between  the  fingers  and  thumb  under  deep  pressure  during 
expiration  and  inspiration,  while  the  patient  is  in  a  recumbent  pos- 
ture with  his  legs  flexed,  or  the  intestine  should  be  manipulated 
between  the  hands  during  bimanual  palpation. 

Examination  of  the  colonic  segments  in  this  way  frequently  aids 
one  in  concluding  if  the  gut  is  inflamed,  ulcerated,  displaced,  firm  and 
tube-like,  spasmodically  contracted,  contains  enteroliths  or  multiple 
pasty  or  nodular  fecal  impactions,  under  which  circumstances  the 
intestine  feels  like  a  string  of  sausage  or  is  in\olved  by  a  malignant 
growth. 

In  diarrheal  subjects,  sore  spots,  painful  points,  and  isolated  gas 


COLONIC    INFLATION  29 

collections  should  be  carefulK'  noled,  because  they  are  indicative  of 
ulcers,  inflamed  areas,  and  obstructive  lesions  which  excite  loose 
movements,  and  palpation  of  the  hepatic,  duodenal,  and  pancreatic 
regions  should  not  be  overlooked,  because  of  the  correlation  of  these 
organs,  which,  when  diseased,  frequently  lead  to  diarrhea. 

Spinal  palpation  should  be  practised  as  a  routine  measure,  because 
in  certain  gastro-intestinal  affections  (ulcers,  inflammation,  and 
malignancy)  the  skin  at  the  sides  of  the  spine  possesses  sensitive  areas 
which  make  the  patient  wince  when  pressed  upon.  In  persons  who 
have  »astric  ulcer  the  integument  at  the  left  of  the  tenth,  eleventh,  and 
twelfth  dorsal  vertebrae  is  sensitive,  while  in  those  afllicted  with  chole- 
lithiasis the  same  regions  on  the  opposite  side  of  the  spine  are  in- 
volved, but  in  neurasthenia  the  skin  on  both  sides  of  the  vertebra 
(especially  interscapular  and  sacral  regions)  are  painful  to  the  touch. 
In  some  instances  the  musculature  adjacent  to  the  spine  is  rigid  in 
spots,  and  these,  together  with  the  painful  points  in  the  integument, 
can  be  determined  by  pressing  with  the  finger-tips  first  on  one  side 
and  then  on  the  other,  in  successive  stages,  until  the  entire  region  of 
the  vertebral  column  has  been  covered. 

Inflation  of  the  Stomach  and  Colon. — Distention  of  the  stomach  and 
colon  with  air,  gas,  or  water  is  a  valuable  diagnostic  aid,  particularly 
when  it  is  employed  in  conjunction  with  inspection,  percussion,  and  pal- 
pation, because  it  permits  the  examiner  to  determine  with  reasonable 
accuracy  their  position,  size,  and  outline  and  differentiate  them  from 
other  organs,  neoplasms,  and  tumefactions. 

Following  gas  distention  one  can  obtain  a  clear  tympanitic  note 
over  the  stomach,  which  enables  him  to  diagnose  dilatation  and  pto- 
sis of  the  organ,  detect  consequent  augmented  peristaltic  waves, 
locate  tumors  through  change  and  position  of  the  stomach  as  inflation 
takes  place,  in  exceptional  instances  locate  stenosis,  and,  when  the 
gas  rapidly  escapes  into  the  bowel,  to  form  an  idea  as  to  whether  or 
not  pyloric  resistance  is  below  par. 

Colonic  inflation  is  extremely  valuable  for  locating  tender  and 
painful  si)ots,  clearing  up  the  diagnosis  in  obscure  intestinal  lesions, 
and  should  not  l)e  omitted  because  of  its  simplicity  and  the  fact  that 
it  is  devoid  of  danger  when  intelligently  practised.  Following  dis- 
tention the  intestine  can  be  traced  more  accurately  throughout  its 
course;  ptosis  of  colonic  segments  (congenital  or  acquired),  enlarge- 
ments, angulations,  invagination,  and  points  of  obstruction  (irre- 
specti\c  of  cause)  unrecognizable  by  other  means  can  often  be  dift'er- 
entialed.  Tumors  in  the  gut  wall  are  more  easily  made  out,  neo- 
plasms behind  the  peritoneum,  tumors,  and  enlargement  of  other 
organs  discernible  before  (particularly  in  persons  having  a  thin  abdo- 
men) disappear  as  the  intestine  rises  up  with  inflation,  and  growths  in 
the  colon  can  occasionally  be  observed  or  felt  to  change  their  posi- 
tion along  with  the  gut.  Perforation  should  be  suspected  when  air, 
gas,  or  water  fail  to  distend  the  colon,  though  it  is  possible  that  the 
distending   median   escapes   past    the   ileocecal    vaK'e    into   the  small 


30  EXAMINATION    AND    DIAGNOSIS 

bowel  and  not  into  the  free  peritoneal  ca\ity.  Both  the  stomach  and 
intestine  should  be  emptied  prior  to  inflation. 

In  supposed  cases  of  large  bowel  obstruction  the  colon  should  be 
percussed  and  palpated  throughout  its  course,  both  before  and  fol- 
lowing distention,  because  the  gut  will  be  found  more  tympanitic 
above  the  stenosis  prior  to  inflation,  owing  to  the  collected  intestinal 
gases,  than  below,  while  subsequent  to  the  entrance  of  air  into  the 
bowel  the  reverse  is  the  case  because  of  the  excessive  amount  of  arti- 
ficial air  or  gas  in  the  terminal  segment  of  intestine. 

A  rubber  bag,  distended  with  air  or  water,  is  frequently  employed 
by  the  author  to  test  the  strength  of  the  external  and  O'Beirne's 
sphincters,  and  measure  the  capacity  of  the  rectum  and  locate  angu- 
lations and  strictures  in  the  sigmoid  flexure  through  which  the  bag 
has  been  introduced.  In  one  instance  following  cecostomy,  by  in- 
flating the  colon  above  through  the  artificial  opening  and  from  below 
by  way  of  the  anus,  a  stricture  was  plainly  defined  in  the  central  or 
dependent  portion  of  the  transverse  colon.  This  patient  suffered 
from  extensive  ulcerative  entamebic  colitis,  for  the  relief  of  which 
cecostomy  was  performed,  and  a  stenosis  was  suspected  when  regurgi- 
tation of  the  fluid  through  the  cecum  invariably  followed  its  intro- 
duction. A  cure  followed  resection  of  several  inches  of  gut  and  sub- 
sequent medicated  through-and-through  irrigation.  A  definite  idea 
may  be  formed  in  regard  to  the  location  of  an  obstruction  conse- 
quent upon  angulation,  invagination,  twists,  strictures,  or  ptosis, 
and  the  size  of  the  dilated  colon  can  be  accurately  determined  by 
measuring  the  amount  of  gas  or  water  required  to  fill  the  bowel  when 
dilated,  or  the  gut  below  when  blocked.  Bowel  inflation  or  disten- 
tion with  water  or  air  is  frequently  impracticable  because  the  pain 
induced  precludes  the  introduction  of  an  amount  sufficient  to  accom- 
plish the  desired  result.  Inflation  with  air  or  gas  causes  the  patient 
more  suffering  than  does  filling  the  bowel  with  water,  especially  when 
the  latter  is  employed  warm  or  hot  (80°  to  110°  F.),  because  the  heat 
soothes  the  intestinal  musculature  and  nerves  and  minimizes  entero- 
spasm;  warm  oil  is  even  more  sedative  than  water. 

The  technic  of  gastric  and  colonic  inflation  and  distention  with  air 
and  water  is  comparatively  simple,  but  when  carelessly  done  is  dan- 
gerous, because  the  healthy  viscus  may  be,  and  the  diseased  (ulcerated) 
one  is  particularly  apt  to  be,  ruptured. 

Air  and  gas  are  preferable  for  the  stomach,  and  may  be  intro- 
duced by  means  of  an  ordinary  straight  or  stomach-tube,  to  which  is 
attached  a  workable  inflating  bulb  of  fair  size,  or  gases  may  be  formed 
in  the  stomach  by  having  the  patient  drink  a  half-glass  of  water  con- 
taining a  dram  (4I  gm.)  of  tartaric  acid,  and  follow  this  shortly  with 
a  like  amount  of  water  in  which  has  been  dissolved  a  teaspoonful  of 
sodium  bicarbonate,  a  chemical  comi:)ination  which  leads  to  the  rapid 
formation  of  carbonic  acid  gas  which  inflates  the  stomach.  As  soon 
as  possible  gas  should  be  piped  off  to  relieve  the  patient  and  lessen  the 
danger  of  perforation  should  there  be  an  ulcer  or  a  stricture.     In  the 


CHEMIC,    MACROSCOPIC,    AND    MICROSCOPIC    EXAMINATION  3 1 

presence  of  known   ulcers,  strictures,   cancers,   adhesions,  and   heart 
affections,  inflation  is  contra-indicated. 

The  simplest,  quickest,  emd  best  way  of  inflating  the  colon  is  to 
introduce  a  rectal  or  colon  tube,  and  connect  it  with  a  compressed-air 
apparatus,  when  the  air  is  permitted  to  slowly  fill  the  gut,  while 
the  thumb  is  kept  upon  the  valve  connected  with  the  tank  to  prevent 
the  too  rapid  escape  of  air  or  gas  into  the  bowel,  which  would  cause 
considerable  pain  or  possible  rupture  of  the  intestine.  In  the  absence 
of  a  tank  or  a  bulb,  inverted  siphons  of  Vichy  may  be  substituted,  or 
solutions  of  soda  and  tartaric  acid  may  be  injected  into  the  rectum  to 
form  gas  within  the  intestine.  Air  or  gas  may  be  retained  as  long  as 
required  by  means  of  the  Strauss  inflating  apparatus  (Fig.  3)  or  by 
the  introduction  of  a  large-sized  self-retaining  anal  dilator  simultaneous 
with  removal  of  the  inflating  tube.  Pain  incident  to  colonic  disten- 
tion varies  according  to  the  amount  of  air,  gas,  or  water  employed, 


AV 


Fig.  3. — Inflating  and  irrigating  rectal  tube. 


and  the  rapidity  with  w'hich  it  is  introduced,  and  instant  relief  usu- 
alh-  follows  passage  of  the  proctoscope  or  colon  tube  and  escape  of 
the  air,  but  when  the  distending  agent  is  not  permitted  to  escape,  the 
patient  suffers  several  hours  from  colic  or  collapse.  Water  is  prefer- 
able to  air  or  gas  in  cases  of  coloptosis  and  angulation,  because,  owing 
to  its  weight,  sagging  and  kinks  are  emphasized.  B\-  siphoning 
off  the  water  following  distention  one  can  diagnose  a  colitis,  ulcer,  or 
cancer  by  noting  the  contained  blood,  mucus,  pus,  or  fragments  of 
tissue  as  the  fluid  runs  out,  or,  when  this  fails,  by  filtration  or  micro- 
scopic examination  of  the  fluid.  Inflation  for  therapeutic  and  diag- 
nostic purposes  can,  if  necessary,  be  limited  to  the  rectum  by  block- 
ing the  bowel  at  the  anus  and  sigmoid  with  a  water-  or  pneumatic  bag; 
or  the  colon  can  be  filled  and  the  distending  agent  retained  within  it 
as  long  as  desired  by  means  of  the  inflating  apparatus  shown  in  Fig.  3. 
Chemic,  Macroscopic,  and  Microscopic  Examination  of  the 
Stomach  Contents. — When  the  size,  shape,  and  position  of  the  stom- 


32  EXAMINATION    AND    DIAGNOSIS 

ach  have  been  determined  through  the  aid  of  inspection,  percussion, 
oscultation,  clapotemefit,  and  palpation,  with  or  without  distention 
of  the  organ  with  gas  or  fluid,  the  contents  of  the  stomach  should  be 
withdrawn  at  stated  periods  following  normal  and  test-meals,  and 
submitted  to  chemic,  macroscopic,  and  microscopic  examination,  to 
determine  whether  the  secretory,  motor,  and  absorptive  functions  of 
the  organ  are  deranged,  and,  if  so,  the  cause,  extent,  and  character 
of  the  disturbance.  This  precaution  is  most  essential  in  obscure 
diarrhea  of  apparent  alimentary  origin,  because,  as  will  be  seen  in 
the  special  chapter  devoted  to  the  subject,  there  are  many  varieties 
of  gastrogenic  diarrheas,  some  of  which  cannot  be  diagnosed  except 
by  exclusion  accomplished  through  the  aid  of  a  careful  gastric  anal- 
ysis. 

The  etiologic  factors-  in  diarrhea  gastrica  are  at  times  difficult  to 
ascertain,  because  in  some  instances  the  trouble  is  due  solely  to  func- 
tional errors  in  the  stomach;  in  others,  to  associated  general  disturb- 
ances, duodenal  or  pancreatic  disease,  or  a  catarrhal  inflammation  of 
the  small  or  large  bowel,  which  tend  to  increase  the  number  of  evacu- 
ations. Gastrogenic  diarrhea  is,  in  most  instances,  traceable  to 
suhacidity  or  achylia  gastrica,  hyperacidity,  atony,  motor  insiifficency 
of  the  stomach,  pyloric  stenosis  or  malignancy,  alone  or  combined, 
conditions  which  are  fully  discussed  elsewhere.  In  these  varieties  of 
loose  movements  analytic  study  of  the  gastric,  contents  should  be 
reinforced  by  a  careful  examination  of  the  feces,  for  A.  Smith  has 
demonstrated  by  his  test-meal  that  connective-tissue  remnants 
are  present  in  the  stools  of  lienteric  diarrhea  (diarrhea  gastrica) ; 
while  Einhorn,  Oppler,  Schutz,  and  others  have  done  much  to  estab- 
lish the  individuality  of  the  above-named  types  of  gastrogenic  dis- 
turbances. 

Test-meals. — Some  patients  who  suffer  from  stomach  trouble 
vomit  frequently,  and  a  portion  of  the  contents  can  in  this  way  be 
obtained  for  examination,  but  this  is  unsatisfactory,  and  it  should  be 
siphoned  or  suctioned  out  through  a  stomach-tube  at  a  specified  time 
following  the  administration  of  a  test-meal,  according  to  the  plan 
of  Riegel,  Germain,  Sevec,  or  breakfast  of  Ewald  and  Boas  (the 
most  universally  used).  Better  results  are  obtained  when  the  juice 
and  admixed  solids  are  withdrawn  during  the  height  of  digestion,  or 
one  hour  after  the  patient  has  eaten  one  or  two  rolls  and  drunk  a  cup 
of  tea  or  water  (Ewald- Boas  meal),  or  from  two  to  four  hours  follow- 
ing a  mixed  meal,  including  broth,  meat,  potatoes,  and  a  roll  (Riegel). 

The  test-meal  should  be  taken  upon  an  empty  stomach,  and  no 
attempt  should  be  made  to  remove  it  until  digestion  is  well  under 
way  or  completed,  otherwise  the  tube  will  become  clogged  or  the 
obtained  juices  will  not  be  in  the  right  ratio,  which  varies  during 
the  different  stages  of  digestion. 

Methods  of  Removing  Stomach  Contents. — Einhorn'  has  designed 
a  diminutive  silver  capsule-shaped  stomach  bucket,  which  he  has  the 
'  Diseases  of  the  Stomach,  4th  ed.,  1906,  p.  81. 


METHODS    OF    RPZMOVING    STOMACH    CONTEXTS  33 

patient  swalhnv,  and  afterward  withdraws  by  means  of  an  attached 
silk  cord  after  the  bucket  has  remained  in  the  stomach  for  a  few 
moments  and  become  partially  or  completely  filled  with  gastric  in- 
gredients; but  this  apparatus  is  objectional)le  because  it  is  difficult 
for  solid  matter  to  enter  the  bucket,  and  a  sufficient  amount  of  the 
contents  is  not  always  withdrawn  to  admit  a  perfect  examination, 
and,  further,  because  patients  object  to  swallowing  so  large  a  metal 
body,  owing  to  the  accompanying  nausea  and  fear  of  its  becoming 
detached,  and  because  its  withdrawal  induces  considerable  discom- 
fort. Of  the  paraphernalia  designed  for  extracting  the  gastric  con- 
tents for  analysis  the  stomach-ttibe  is  the  most  practical  because  it  is 
inexpensive,  is  easy  to  introduce,  cannot  become  detached,  does  not 
injure  the  mucosa,  is  not  complicated,  and,  when  resorted  to  under 
proper  conditions,  accomplishes  its  purpose. 

Tubes,  to  be  of  the  greatest  use,  should  be  made  of  soft  rubber,  and 
sufficiently  thick  to  give  them  a  degree  of  stiffness,  have  a  fair-sized 
opening  in  their  conic  distal  end,  and  velvet  eyes  or  slits  scattered 
along  the  sides  for  an  inch  or  more  above  the  lower  extremity,  so  that 
both  fluids  and  solids  can  readily  enter  it,  and  should  be  about  30 
inches  (75  cm.)  in  length.  Small  tubes  should  be  employed  for  chil- 
dren, and  the  size  of  the  larger  variety  should  be  varied  to  meet  the 
conditions  in  adults  of  unusual  stature,  and  those  who  suffer  from 
spasmodic  or  organic  stenosis  of  the  esophagus.  An  aspirating  bulb, 
located  about  the  center  of  the  pipe,  aids  in  obtaining  a  free  flow  of 
the  gastric  contents  through  its  suction  action  when  indicated,  as,  for 
instance,  when  the  tube  is  blocked  by  mucus. 

Stomach-tubes  are  more  useful  for  diagnostic  than  therapeutic 
purposes,  and  are  rarely  used  in  the  treatment  of  gastric  affections 
other  than  to  get  rid  of  decomposing  material  in  cancer  cases  and 
pyloric  stenosis,  and  to  wash  out  poisons  which  have  been  swallowed 
accidentally  or  taken  with  suicidal  intent. 

Soft  pipes  are  difficult  to  completely  sterilize  without  injury,  and 
it  is  advisable  for  each  patient  to  possess  his  own  marked  tube.  Those 
used  for  clinic  purposes  should  be  carefully  rinsed  and  kept  in  a  bi- 
chlorid  solution,  but,  even  with  this  precaution,  it  is  unwise  to  use 
on  a  healthy  person  a  pipe  which  has  been  swallowed  by  an  individual 
afflicted  with  sNphilis,  tuberculosis,  or  infectious  diseases  of  the 
mouth  or  teeth. 

The  patient  in\ariabl\-  objects  to  having  the  tube  introduced  the 
first  time,  but  the  fear  can  be  dispelled  in  most  instances  by  explain- 
ing the  process,  and  informing  him  that  the  consequent  discomfort  is 
of  short  duration,  and  that  removal  of  the  tube  will  not  cause  pain 
or  vomiting.  The  subject  can  stand  or  remain  in  the  recumbent  pos- 
ture during  introduction  of  the  tube  and  extraction  of  the  contents, 
but,  as  a  rule,  this  can  be  accomplished  with  greater  ease  for  the  phys- 
ician and  less  discomfort  to  the  patient  in  the  upright  sitting  position, 
with  the  head  and  shoulders  slightly  inclined  forward,  wdth  the  attend- 
ant standing  to  the  right  behind  the  chair,  so  that  he  may  hold  the 


34 


EXAMINATION    AND    DIAGNOSIS 


tube  in  the  patient's  mouth  with  the  left,  while  he  aspirates  or  manipu- 
lates the  outer  end  with  the  right  hand  (Fig.  4).  In  this  way  the 
contents  can  be  certainly  and  slowly  expressed  into  the  receiving 
vessel. 

In  normal  subjects  depression  of  the  tongue  is  unnecessary,  but 
the  patient  should  be  told  to  close  his  mouth  and  swallow  when  the 
tube  reaches  the  epiglottis,  independently  or  guided  with  the  finger, 
and,  as  he  does  so,  it  should  be  quickly  and  gently  pushed  downward 
through  the  esophagus  into  the  stomach  as  the  patient,  under  instruc- 
tion, breathes  deeply. 


Fig.  4. — Rermnnnji  the  stomach  content?  for  examination  following  a  test-meal. 


Before  introduction  of  the  tube  false  teeth  should  be  removed, 
and  it  should  be  ascertained  if  there  are  contra-indications  to  its 
passage,  such  as  angina  pectoris,  thoracic  aneurysm,  serious  heart 
lesions,  phthisis,  bronchitis,  gastric  ulcer  or  carcinoma,  old  age,  epi- 
lepsy, and  other  conditions  wherein  straining  while  xomiting  might 
prove  dangerous. 

Formerly  the  author  required  his  office  assistants  to  examine 
chemically,  macroscopically,  and  microscopically  the  gastric  contents 
of  patients  sutYering  from  diarrhea  wherein  it  was  thought  that  the 


GASTROSCOPY    AND    GASTRODIAPHAXY  35 

source  of  the  trouble  was  solely  or  partially  located  in  the  stomach, 
but  in  recent  years  he  has  referred  the  collected  contents  to  the  labora- 
tory for  examination,  which,  after  all,  is  the  best  place,  because  the 
work  is  too  laborious  and  complicated  t(j  be  proi)erl\-  done  in  a  i)ri- 
vate  office. 

It  has  been  pointed  out  that  subacidity,  hyperacidity,  atony, 
motor  insufficiency  of  the  stomach,  pyloric  stenosis  or  malignancy, 
singly  or  together,  may  incite  ^astrogenic  diarrhea. 

To  describe  the  technic  of  the  numerous  tests  and  methods  ief]uired 
for  the  identification  of  these  aljnormal  conditions  and  the  part  played 
b\-  them  in  the  disturbance  would  recjuire  more  time,  labor,  and  space 
than  is  warranted  in  a  work  of  this  character,  and,  because  of  this, 
ihf  author  refers  the  reader  desiring  such  information  to  the  standard 
W(jrks  (jf  Cohnheim,  Kinhcjrn,  Boas,  Reade,  Xothnagel,  Bassler, 
Ewald,  and  others  who  have  dealt  with  the  subject  in  a  comprehen- 
sive and  thoroughly  practical  manner. 

Gastroscopy  and  Gastrodiaphany. — When  the  history,  external 
examination,  and  anahsis  of  the  stomach  contents  fail  to  estal)lish 
a  diagnosis  in  diarrhea  geistrica  the  stomach  should  be  studied  by  trans- 
illumination (gastrodiaphany)  of  its  anterior  wall,  and  its  interior 
inspected  and  palpated  through  the  aid  of  the  gastroscope  and  arti- 
ficial light,  for,  with  the  assistance  of  these  diagnostic  adjuvants,  the 
colon  and  thickness  of  the  mucosa  can  be  determined,  ulcers  located, 
and  tumors  outlined  in  a  fair  percentage  of  cases.  The  organ  is  rather 
difficult  to  examine  with  gastric  illuminating  instruments  because 
of  their  size,  great  length,  and  skill  required  for  their  introduction 
and  subsequent  manipulation;  consequently,  at  present  gastroscopy 
is  not  as  reliable  a  means  of  diagnosis  as  are  cystoscopy  or  proctoscopy. 
Direct  inspection  of  the  stomach  is  more  reliable  for  determining 
the  character  of  lesions  in  the  mucosa  than  skiagraphs,  but  the  latter 
(discussed  elsewhere  in  the  chapter)  are  the  most  trustworthy  for 
outlining  the  organ,  locating  strictures,  tumors,  displacements,  and 
deformities,  both  following  the  administration  of  a  carbonate  of  bis- 
muth meal  or  filling  the  organ  with  a  solution  of  the  chemical  mucilage 
of  acacia  and  water,  and,  in  addition,  one  can  with  the  .r-ray  and 
bismuth  meal  or  injection  observe  the  frequenc\'  and  character  of 
the  gastric  peristaltic  wa\"es,  and  estimate,  with  a  fair  degree  of 
accuracy,  the  time  required  for  the  stomach  to  evacuate  its  contents, 
when  healthy  or  diseased,  by  observation  through  the  fluoroscope 
and  radiographs  made  at  stated  periods  following  entrance  of  the 
meal  or  injected  solution. 

The  author's  colleague.  Dr.  Max  Einhorn,'  was  a  pioneer  in  empha- 
sizing the  diagnostic  importance  of  gastrodiaphany  and  gastroscopy, 
and  early  designed  instruments  for  both  purposes.  Recently,  how- 
ever. Dr.  Chevallier  Jackson-  has  improved  upon  his  apparatus,  and 
designed    an    instrument    serviceable    both    for    esophagoscopy    and 

'  "Die  Gastrocliaphanie,"  New  Yorker  med.  Monatsschrift,  Nov.,  1889. 
-  Medical  Record,  .April  6,  1907;  Jour.  .\mer.  Med.  -Assoc,  October  26,  1907, 


36  EXAMINATION    AND    DIAGNOSIS 

gastroscopy.  that  can  also  be  used  for  drainage  and  suction  of  the 
secretions,  and  claims  that  with  his  appliance  one  can  explore  from 
one-half  to  three-quarters  of  the  total  gastric  mucosa  when  the 
patient  is  profoundly  anesthetized,  and  suggests  that  cocain  is  pre- 
ferable when  the  esophagus  is  to  be  examined.  Better  results  are 
obtained  when  gastroscopy  has  been  preceded  by  gastric  lavage  and 
morphin  or  atropin  have  been  administered  to  minimize  the  trouble 
from  the  secretions,  which  frequently  obscure  or  put  out  the  light 
when  the  examination  is  made  in  a  darkened  room. 

Examination  of  Feces. — The  value  of  fecal  examination  has  been 
greatly  underestimated,  owing  to  the  fact  that  it  is  seldom  practised 
by  many  physicians:  (a)  because  of  their  repugnance  to  such  work; 
(b)  the  difificulty  in  keeping  the  stool  warm  for  the  necessary  length 
of  time;  and  (c)  their  ignorance  as  to  the  technic  of  making  the  ex- 
amination under  varying  conditions. 

An  analysis  of  the  excreta  should  be  made  as  a  routine  measure 
in  the  presence  of  diarrhea,  because  it  would  in  nearly  every  instance 
give  some  idea  as  to  the  nature  of  the  disturbance  causing  the  in- 
creased fluid  evacuations.  A  study  of  the  gastric  contents  enables 
one  to  judge  if  the  proportions  of  the  stomach  juices  are  relatively 
normal  and  ascertain  if  digestion  within  the  organ  is  being  properly 
carried  out,  while  investigation  of  the  feces  will  indicate  if  normal 
secretion,  digestion,  and  absorption  are  taking  place  within  the  small 
intestine  and  colon,  and  whether  or  not  there  are  disturbing  factors 
in  the  bowel  which  would  interfere  with  these  functions  or  in  other 
ways  favor  acute  or  chronic  diarrhea. 

Usually,  normal  and  pathologic  feces  have  a  disgusting  odor,  and 
because  of  this  it  is  advisable  to  get  them  out  of  the  office  or  hospital 
and  to  the  laboratory  as  soon  as  possible.  To  this  end  the  author, 
as  soon  as  he  has  made  a  macroscopic  study  of  the  stool,  places  all  or 
a  portion  of  it  in  a  Thermos  bottle  or  other  vehicle  wherein  it  can  be 
transported  in  a  warm  state  to  the  laboratory,  except  in  cases  where 
an  immediate  diagnosis  is  imperative,  or  he  wishes  to  demonstrate  to 
the  physician  bringing  the  case  entameba?,  Balantidium  coli,  Shiga's 
or  Flexner-Harris  bacilli,  parasites,  their  ova,  or  other  micro-organ- 
isms supposedly  responsible  for  the  diarrhea. 

Naturally  in  diarrhea  the  evacuations  are  changed  from  the  nor- 
mal in  form,  color,  consistence,  and  frequency,  but  the  extent  to  which 
such  changes  occur  varies  according  to  the  cause  of  the  disturbance, 
severity  of  the  diarrhea,  diet,  amount  of  water  consumed,  and  the 
character  of  the  medicines  administered  for  its  control,  and  they 
may  be  soft,  mushy  or  fluid,  and  normal  in  amount  or  profuse. 

It  is  advisable  to  consider  the  ai>e  of  the  patient  in  individuals 
supposedly  affected  with  diarrhea,  and  to  bear  in  mind  that  in  health 
an  adult  should  have  one,  a  child  two,  and  an  infant  four  or  more 
stools  daily,  and  that  some  individuals  normally  void  more  than  the 
usual  number  of  evacuations  in  twenty-four  hours  and  remain  well. 

Perfectly  normal  stools  ha\e  a  slightly  disagreeable  odor,  but  when 


EXAMIXATIOX    OF    FECES  37 

they  contain  indol,  skatol,  sulphuretted  hydrogen,  menthane,  and 
phosphin  in  abundance,  as  may  occur  in  the  presence  of  Hver  affec- 
tions, gastro-enteritis,  and  sometimes  constipation,  they  are  particu- 
larly offensi\e.  In  dysenteric,  tubercular,  gonorrheal,  syphilitic, 
and  other  forms  of  colitis  complicated  by  extensive  ulceration,  the 
dejecta  possesses  a  disgusting  odor,  incident  to  the  presence  of  an 
abundance  of  pus,  blood,  and  mucus  which  ha\e  been  unduh-  re- 
tained. 

Occasionally  the  movements  of  patients  afflicted  with  cancer  of 
the  rectum  or  sigmoid  are  characteristically  offensi\e,  but,  as  a  rule, 
the  disagreeable  odor  does  not  appear  until  after  the  growth  has  de- 
generated, ulcers  have  formed,  and  a  discharge  responsible  for  the 
odor  is  produced.  In  choleriform  gastro-intestinal  disturbances, 
wherein  the  chyme  and  feces  are  rapidly  rushed  through  the  alimen- 
tary tract,  the  stools,  which  resemble  rice-ivater,  have  little,  if  any, 
odor. 

As  a  general  rule,  when  the  movements  possess  an  ammoniacal 
odor  it  results  from  a  decomposition  of  urine  which  has  been  \oided 
along  with  the  feces. 

Fecal  analysis,  to  be  effective  in  obscure  cases  of  diarrhea,  should 
embrace  a  careful  macroscopic,  chemic,  and  microscopic  examination 
of  the  excreta  made  on  different  days  following  ordinary  and  test- 
meals. 

Macroscopic  Examination. — By  means  of  macroscopic  examination 
of  the  stools  one  can  determine  if  they  are  slight  or  profuse,  their  color, 
form,  and  if  they  contain  sections  of  or  entire  worms  (tapeworms, 
Ascaris  lumbricoides),  tissue  debris  (polypi,  degenerated  cancer,  etc.), 
intestinal  sand,  gall-stones,  pancreatic  calculi,  enteroliths,  foreign 
bodies,  scybala,  bismuth  accumulations,  mucus  (gelatinous,  casts  or 
threads),  pus,  blood,  or  food  remnants.  Considerable  information 
can  be  gained  by  studying  the  color  of  the  dejecta,  which  is  subject  to 
marked  changes  in  health  and  disease.  Milk  (diet)  colors  the  stools 
a  light  yellow;  red  wine,  huckleberries,  and  salts  of  iron  and  magensia, 
brownish  black;  rhubarb,  santonin,  and  senna,  yellot^';  calomel,  green; 
salol  and  beta-naphthol,  violet;  bismuth,  black;  methylene-blue,  bluish 
green;  mucus  in  large  quantities,  yellowish  gray;  and  cholera,  straw 
colored. 

In  aggravated  types  of  diarrhea  the  stools  ha\e  no  more /or;;;  than 
water;  when  less  severe  they  flatten  out  in  the  chamber  like  a  pan- 
cake; but  when  the  patient  does  not  have  more  than  two  or  three 
movements  daily  the  stools  are  semisolid.  Some  idea  may  be  ob- 
tained as  to  the  cause  of  the  trouble  by  studying  their  form,  for 
when  the  sphincter  is  irritable  and  spasmodically  contracts,  or  there 
is  a  stricture,  polyp,  or  cancer  located  in  the  rectum,  the  feces  may  be 
evacuated  grooved,  like  strings,  indented  or  flat,  and  tape-  or  round 
and  pencil-like.  Obstructions  located  in  the  small  intestine  and 
colon  do  not  materially  affect  the  form  of  the  excreta  because  fluid 
feces  escape  by  them  to  become  solidified  and  be  discharged  in  normal 


38  EXAMINATION    AND    DIAGNOSIS 

shape.  Occasionally  in  subjects  who  suffer  from  diarrhea  the  feces 
are  unduly  retained,  and  large  firm  or  small  round  hardened  fecal 
masses  (scybala)  collect  and  enemata  are  required  to  dislodge  them. 

Blood  in  the  stools  is  indicative  of  certain  gastro-intestinal  affec- 
tions. When  discharged  bright  red  it  is  usually  incident  to  tumors, 
ulcers,  fissures,  or  hemorrhoids  located  in  the  rectum  or  anal  canal,  and 
the  bleeding  may  be  copious  or  slight,  depending  upon  the  size  of  the 
vessel  involved.  When  the  stools  are  dark  brown  or  tar  colored  and 
resemble  coffee-grounds,  bleeding  is  from  the  stomach,  small  intestine, 
or  upper  colon,  and  the  blood  has  been  retained  sufficiently  long  for 
it  to  become  clotted  and  undergo  marked  changes. 

Mucus  in  one  form  or  another  is  to  be  seen  in  the  movements  of 
nearly  all  individuals  who  suffer  from  diarrhea,  and  may  vary  greatly 
in  character,  for  it  may  appear  as  flakes  or  patches  independently,  or 
upon  impacted  fecal  masses,  as  casts  in  membranous  enterocolitis, 
and  may  be  gelatinous  in  jejunal  diarrhea  and  tenacious  in  proctitis, 
etc.  Formerly,  sago-like  bodies  of  vegetable  origin  resembling  frog- 
spawn  were  frequently  mistaken  for  coagulated  mucus. 

It  is  well  to  bear  in  mind  that  mucus  is  a  normal  product  of  the 
bowel,  and  that  the  amount  secreted  may  be  materially  increased  by 
catharsis,  psychic  emotions,  and  ner\'ous  derangements,  independent 
of  definite  intestinal  lesions.  When  mucus  persistently  shows  in  the 
stools  it  indicates  a  catarrhal  state  of  the  small  intestine,  colon,  or 
both ;  but  when  it  is  admixed  with  blood  and  pus  it  points  to  serious 
organic  changes  and  indicates  that  the  mucosa  is  eroded  or  affected 
by  ulcerative,  stenotic,  or  cancerous  processes.  When  the  mucus  is 
very  abundant  and  tenacious  upon  the  feces,  or  when  voided  inde- 
pendently, the  chief  disturbance  will  be  found  in  the  lower  sigmoid 
flexure  or  rectum. 

Membranous  casts  are  usually  formed  in  the  colon,  and  when 
they  closely  resemble  the  bowel  the  probabilities  are  that  they  have 
formed  in  the  descending  colon,  sigmoid  flexure,  or  upper  rectum. 
It  is  extremely  diflicult  to  determine  from  what  part  of  the  intestine 
mucus  comes,  but  when  it  is  secreted  in  the  small  gut  it  is  usually 
not  visible  to  the  naked  eye.  but  can  be  seen  through  the  micro- 
scope, and  gives  to  the  stool  a  glistening  appearance. 

When  there  is  a  hypertrophic  inflammation  of  the  sigmoid  flexure, 
rectum,  or  anus  the  inner  lining  of  the  bowel  looks  wet  and  is  bathed 
with  mucus,  which  slips  out  through  the  speculum  when  the  patient 
is  requested  to  strain.  In  membranous  colitis,  rope-like  strings  can 
sometimes  be  seen  projecting  from  the  sigmoid  into  the  rectum,  and 
in  catarrhal  inflammation  of  the  colon,  accompanied  by  the  forma- 
tion of  tenacious  mucus  in  large  amounts,  it  can  be  seen  through  the 
proctoscope  swinging  downward  from  one  rectal  valve  to  another,  and 
under  reflected  light  looks  as  if  the  rectum  was  divided  by  a  glass 
partition. 

In  acute  proctitis  the  patient  complains  of  tenesmus  and  fre- 
quently voids  mucus  alone  or  admixed  with  softened  feces,  but  when 


EXAMINATION    OF    FECES  39 

the  latter  are  firm  the  mucus  covers  the  end  or  surrounds  the  entire 
fecal  bolus  when  expelled. 

Pus. — Thick,  >ello\v  pus  is  visible  macroscopically  only  in  the 
presence  of  spinal,  abdominal,  pelvic,  and  rectal  abscesses  or  fistulae, 
and  when  suppurating  diverticula  of  the  colon,  sigmoid,  or  rectum  dis- 
charge into  the  bowel.  Brick-dust  colored  or  pus  admixed  with  blood 
and  mucus  is  very  much  more  common,  and  may  be  encountered  in 
the  various  forms  of  ulcerative  colitis,  strictures,  and  cancers,  and 
when  abundant  indicates  that  the  lesions  are  numerous,  or  if  single, 
that  the  mucosa  is  extensively  involved;  but  when  the  amount  is 
slight  and  streaks  the  feces  or  precedes  their  expulsion,  it  points  to  an 
ulcer,  fissure,  or  blind  internal  fistula  in  the  lower  rectum  or  anal  canal. 

Indigestible  or  partially  digested  food  remnants,  such  as  peas, 
strings  of  beans,  mushrooms,  potatoes,  and  other  vegetables,  can  be 
frequently  seen  with  the  naked  eye,  as  can  particles  of  meat,  con- 
nective tissue,  and  fats,  but  less  often  and  not  so  plainly,  except 
when  they  are  present  in  considerable  amounts,  which  is  indicative  of 
impaired  gastrogenic  or  in  enterogenic  digestion. 

Finally,  fatty  stools  the  result  of  obstructive  jaundice,  overfat 
eating,  and  disease  of  the  pancreas  or  its  duct  are  macroscopically 
recognizable  because  of  their  oily  or  greasy  appearance. 

Chemic  Examination  of  the  Feces. — Ordinarily  the  feces  are  neutral 
or  slightly  alkaline  in  reaction,  and  sometimes  there  is  a  difference 
between  the  surface  of  and  body  of  the  feces,  and  both  should  be 
tested.  Acidity  of  the  excreta  is  augmented  by  a  vegetable  diet  and 
blocking  of  the  bile-duct,  and  normally  a.  prepared  stool  changes  blue 
litmus-paper  to  red  and  the  red  to  blue. 

By  Schmidt's  bichlorid  of  mercury  test  healthy  feces  are  colored 
red  (showing  hydrobilirubinj,  but  when  particles  are  given  a  green- 
ish tint  it  indicates  an  abnormal  state  from  unchanged  bile.  The 
reaction  of  the  feces  has  slight  if  any  diagnostic  value  in  determining 
the  etiologv'  of  diarrhea. 

When,  in  spite  of  other  diagnostic  measures,  the  cause  of  the 
gastric  or  intestinal  disturbance  still  remains  undiscovered,  it  is  ad- 
visable to  test  the  feces  for  mucin,  albumin,  pro  peptone  and  peptone, 
starch,  sugar,  fat,  blood,  bile-pigment,  biliary  acids,  urobilin,  steator- 
rhea, trypsin,  diastase,  phenol,  indol,  skatol,  biliary,  intestinal,  and 
pancreatic  concretions,  according  to  the  plan  in  standard  works  de- 
voted to  the  intestines  and  fecal  examination. 

Microscopic  Examination  of  the  Feces. — -In  obscure  cases  macro- 
scopic and  chemic  analysis  inspection  of  the  feces  should  be  reinforced 
by  a  careful  microscopic  examination,  for  in  this  way  important  diag- 
nostic signs  can  be  detected  which  would  otherwise  go  unrecognized. 
To  be  effective,  fecal  specimens  should  be  examined  dry,  moistened 
with  water,  or  diluted  with  Lugol's  solution  or  acetic  acid,  and  com- 
pressed between  cover-glasses  until  transparent,  and  then  inspected 
through  a  low-power  lens  for  the  coarser  elements,  food  remnants, 
tissue  debris,  parasites,  and  entameba',  etc.,  after  which  a  high-power 


40  EXAMINATION    AND    DIA(;N0SIS 

lens  should  be  substituted  that  bacterial  flora,  sarcina?,  Clostridia, 
starch  cells,  etc.,  may  be  detected 

The  findings  within  the  field  vary  considerably,  dependent  upon 
the  diet  and  character  of  the  gastro-intestinal  disturbance,  though 
some  of  the  objects  appear  alike  in  healthy  and  pathologic  dejecta, 
and  it  must  be  determined  whether  they  are  present  in  relatively  too 
small  or  great  amounts  or  numbers. 

Microscopic  inspection  of  the  feces  enables  one  to  discover  whether 
or  not  the  patient  is  properly  digesting  his  meat,  fats,  and  connect- 
ive tissue,  and  in  a  series  of  examinations  the  microscopic  fields  may 
show  muscle-fibers,  fat  globules,  connective-tissue  fibers,  vegetable 
elements,  pus,  blood,  mucus,  epithelia,  tissue  segments  of  worms, 
debris,  eggs  of  intestinal  parasites  (tapeworms,  ascarides,  tricho- 
cephalus,  etc.),  colorless  soaps,  triple  phosphates,  oxalates,  carbonates, 
calcium  and  Charcot-Leyden  crystals,  entamebai,  Shiga's,  Flexner- 
Harris  or  tubercle  bacilli,  Balantidium  coli,  infusoria,  red  and  white 
blood-corpuscles,  starch  cells,  Clostridia  (stain),  plant  cells,  and 
numerous  accidental  and  obligate  micro-organisms,  such  as  the  coli, 
lactis  aerogenes,  bifidus,  aerogenes  capsulatus  (gas  forming),  putrifi- 
cus,  and  Boas-Oppler  bacilli,  etc. 

Pathologic  Significance  of  Microscopic  Findings. — Yellow  stain 
muscle-fibers  in  moderation  are  unimportant,  but  when  numerous 
and  massed,  and  their  striations  and  nuclei  are  undisturbed,  they  in- 
dicate imperfect  gastric  or  pancreatic  digestion,  and  when  they  are 
greenish  in  color,  catarrh  of  the  ileum,  fatty  acid  crystals,  droplets,  and 
diminutive  pieces  of  fat  in  abundance  point  to  blocking  of  the  ductus 
cholidochus  in  liver  and  pancreatic  diseases.  Most  crystals  are  of  no 
diagnostic  importance,  but  the  rhomboid  variety  (hematoidin)  occur 
following  a  hemorrhage,  and  Charcot-Leyden  are  found  in  the  presence 
of  helminthiasis,  typhoid  fever,  dysentery,  and  phthisis.  Epithelia 
in  large  numbers,  together  with  augmentation  of  the  white  blood- 
corpuscles,  denote  a  chronic  inflammatory  state  of  the  mucosa,  and 
when  the  former  are  bile  stained  the  small  bowel  is  involved.  Col- 
orless signifies  catarrhal  colitis,  and  bile-stained  mucous  catarrh 
of  the  upper  small  intestine;  fragments  of  tissue  come  from  polypi, 
degenerating  tumors,  and  ulcerative  processes;  numerous  cholestridia 
and  free  starch  cells  are  signs  of  fermentation  and  catarrhal  and  other 
derangements  of  the  small  gut,  and  sarcina?  complicate  gastric  dila- 
tation. The  cold,  aerogenes  capsulatus,  and  lactis  aerogenes  bacilli  in 
excessive  numbers  point  to  undue  fermentative  and  putrefactive 
changes  in  the  gastro-intestinal  tract;  the  Boas-Oppler  bacillus  is 
commonly  found  in  pyloric  cancer;  entameba-%  the  Shiga- Flexner- 
Harris  bacilli  and  Balantidium  coli  bacillus  indicate  a  dysenteric  coli- 
tis; typhoid  and  tubercle  bacilli,  with  the  usual  manifestations,  signify 
that  the  patient  is  suffering  from  typhoid  or  tubercular  inflammation 
of  the  intestine;  ova  prove  the  presence  within  the  bowel  of  parasites, 
and  the  finding  of  Spirochetes  pallida  demonstrates  that  the  patient 
has  syphilis. 


LAVAGE    IX    Tin:    I)IA(iXOSIS    OF    INTESTINAL    AFFECTIONS  4 1 

Urinary  Examination  in  Diarrhea. — Frequently  a  careful  chemic, 
macroscopic,  and  inicrcjscopic  examination  of  the  urine  is  of  great 
assistance  in  helping  one  to  arrive  at  a  correct  diagnosis  in  the  pres- 
ence of  obscure  gastro-intestinal  affections  complicated  by  acute  or 
chronic  diarrhea,  and  in  detecting  other  causes  which  might  augment 
the  frequency  and  fluidity  of  ilii-  evacuations.  For  example,  the 
amount  of  urine  is  increased  in  diabetic  conditions,  sclerosis,  amyloid- 
osis, and  disturbances  of  the  nervous  system,  and  decreased  in  debili- 
tated indi\iduals  and  those  ha\ing  a  low  blood-pressure,  persons  who 
partake  sparingly  of  water,  and  in  the  presence  of  persistant  hemor- 
rhage, vomiting,  or  diarrhea. 

Indican,  normally  present  in  the  urine,  is  greatly  augmented  wlien 
intestinal  putrefaction  is  active,  when  there  is  chronic  obstruction  of 
the  small  or  large  intestine,  or  the  patient  suffers  from  achylia  gastrica 
or  hyperchlorhydria.  Indicanuria  usually  complicates  all  disturb- 
ances that  minimize  peristaltic  movements,  while  the  proportion  of 
indican  in  the  urine  is  lessened  when  the  bowel  is  active  and  there  is 
no  fecal  stasis. 

Ethereal  sulphuric  acids  are  augmented  by  albuminoid  putrefac- 
tion of  the  feces  when  retained  from  whatever  cause,  and  infectious 
diseases,  like  diphtheria,  scarlet  fever,  and  erysipelas,  and  are  dimin- 
ished by  typhoid,  recurrent,  and  intermittent  fevers. 

In  disturbances  of  the  gastro-intestinal  tract  it  is  important  that 
the  amount  of  acetone  in  the  urine  be  accurately  determined  because 
it  is  increased  (also  diacetic  acid)  in  digestive  disorders,  catarrh  of 
the  stomach,  gastro-enteritis,  intestinal  obstruction,  parasitic  dis- 
eases, fecal  impaction,  peritonitis,  perityphlitis,  cancer  of  the  bowel, 
and  diabetic  conditions.  Some  investigators  claim  that  albumoses 
in  the  urine  indicate  intestinal  decomposition,  typhoid  or  tubercular 
colitis,  and  gastric  ulcers  and  cancer,  while  others  hold  they  are  unim- 
portant as  a  diagnostic  sign. 

Markedly  acid  urine  points  to  indigestion,  intoxication,  and  ner- 
vous states;  bile-pigments  and  acids  may  be  detected  in  the  urine  of 
patients  afflicted  with  certain  hepatic  diseases  (congestion,  cirrhosis, 
cancer,  etc.),  obstruction  of  the  bile-ducts,  or  gastroduodenitis; 
blood  in  the  urine  is  not  an  important  sign  of  gastro-intestinal  affec- 
tions, though  it  has  been  noted  in  gastric  cancer.  Diminished  nitro- 
gen in  the  urine  occasionally  characterizes  hepatic  and  nephritic 
disturbances  and  gastric  cancer;  the  output  of  urea  is  lessened  when 
the  liver  improperly  functionates  or  the  flow  of  bile  is  interfered  with, 
while  under  these  circumstances  the  amount  of  uric  acid  is  augmented; 
glucose  denotes  secondary  digestive  disturbances  from  impaired 
metabolism  rather  than  primary  diseases  of  the  gastro-intestinal 
tract;  urinary  sediments  are  unimportant  as  diagnostic  signs  in  diar- 
rhea consequent  upon  disturbances  within  the  alimentary  tract. 

Rectocolonic  Injections  (Lavage)  in  the  Diagnosis  of  Intestinal 
Affections. — Water  when  injected  into  the  bowel  is  occasionalh'  ser- 
\  iceabJe  in  locating  the  various  types  of  intestinal  obstruction.     When 


42  EXAMINATION    AND    DIAGNOSIS 

only  a  few  ounces  can  be  injected  it  indicates  that  the  block  is  in  the 
rectum;  when  not  more  than  a  pint  can  be  introduced  it  points  to 
obstruction  in  the  sigmoid,  but  when  two  or  more  quarts  flow  readily 
into  the  colon  the  occlusion  is  located  in  the  center  of  the  transverse 
colon  or  higher  up  in  the  large  bowel.  Distention  of  the  great  intes- 
tine in  this  way,  in  connection  with  percussion  and  palpation,  enables 
one  to  outline  the  gut  and  sometimes  to  quickly  determine  if  it  is 
ptotic,  angulated,  or  twisted,  and  to  isolate  tumors  when  during  the 
examination  the  patient  is  changed  from  one  posture  to  another. 
When  other  intestinal  lesions  are  present,  colonic  lavage  is  useful, 
because  washed-out  blood,  mucus,  pus,  foreign  bodies,  food  remnants, 
and  tissue  debris  can  be  discovered  by  macroscopic,  microscopic,  or 
chemic  examination. 

Rectocolonic  Transillumination. — The  author  has  examined  the 
abdomen  along  the  course  of  the  colon  and  sigmoid  flexure  following 
illumination  of  the  gut  in  the  empty  state  and  when  filled  with  water, 
but  the  results  were  so  unsatisfactory  that  he  has  completely  dis- 
carded transillumination,  for  at  best  it  is  useful  only  for  isolating 
tumors  located  in  the  anterior  intestinal  walls,  which  can  be  more 
certainly  identified  by  percussion  and  palpation. 

Blood  Examination. — An  examination  of  the  blood  is  of  value  in 
certain  types  of  diarrhea,  but  a  diagnosis  upon  the  findings  should  not 
be  conclusive  unless  they  fit  in  with  the  history,  clinical  observations, 
and  results  obtained  by  other  diagnostic  measures.  From  the  writer's 
experience  he  inclines  to  the  belief  that  too  much  diagnostic  impor- 
tance is  often  placed  upon  the  blood  count  and  too  little  upon  more 
simple  and  reliable  methods  of  examination. 

The  make-up  of  the  blood  and  its  resistance  to  toxins  vary  widely 
in  health  and  disease  in  different  individuals,  and  this  makes  it  ex- 
tremely difficult  to  estimate  the  value  of  a  blood  examination  in  some 
of  the  more  common  and  serious  diseases  affecting  the  stomach  and 
intestine. 

In  cancer  the  blood  often  undergoes  serious  changes,  which  in 
some  cases  begin  early  and  attack  the  red  blood-corpuscles,  which 
degenerate;  while  in  other  virulent  types  of  malignancy  composition 
of  the  blood  is  but  slightly  impaired. 

In  tuberculosis,  blood  disturbances  are  not  always  characteristic, 
except  in  miliary  tuberculosis,  where  the  leukocyte  count  is  very  low 
and  the  lymphocyte  count  is  relatively  augmented.  Generally  there  is 
leukocytosis  in  tubercular  subjects,  a  condition  which  becomes  aggra- 
vated when  the  peritoneum  is  affected. 

In  sepsis,  leukocytosis  is  rather  characteristic,  and  the  rise  varies 
from  30,000  to  50,000  cells  per  cubic  millimeter.  No  leukocytosis 
indicates  that  the  infection  is  general,  most  virulent,  and  that  it  has 
seriously  impaired  the  function  of  the  bone-marrow,  in  which  case 
there  is  an  increased  number  of  polynuclear  cells,  and  in  some  instances 
an  extreme  degree  of  hemoglobinemia. 

The  blood  in  syphilis,  when  characteristically  changed,  shows  a 


PROCTOSCOPIC    AND    SIGMOIDOSCOPIC    EXAMINATIONS  43 

marked  decrease  in  the  number  of  red  cells  and  a  relatively  low 
hemoglobin  index  almost  as  soon  as  the  chancre  appears,  and  a  mod- 
crate  leukocytosis  during  the  eruptive  stage. 

In  typhoid  fever  consi(lcral)le  information  of  diagnostic  impor- 
tance is  to  be  obtained  through  the  blood  examination  by  determining 
the  relation  of  the  leukocyte  count  to  other  cells,  because  usually  by 
the  end  of  the  second  or  third  week  the  lymphocytes  increase  as 
the  leukocytes,  neutrophils,  and  eosinophils  decrease,  and  since  the 
latter  multiply  a  little  later  as  the  fever  subsides.  As  an  example 
of  the  profound  influence  of  typhoid  fever  upon  the  blood  cells,  Wood 
gives  his  findings  in  a  case  as  follows:  The  leukocyte  count  was 
5000;  polynuclear  neutrophils  were  present  in  a  {)roportion  of  33 
per  cent. ;  large  lymphocytes,  47  per  cent. ;  small  lymphoc\tes,  20  per 
cent. ;  no  basophil  or  eosinophil  cells  were  seen  in  the  500  leukocytes 
counted.  The  Widal  reaction  was  positive  at  i  to  200  within  an 
hour. 

In  appendicitis,  as  in  other  active  abdominal  inflammatory  condi- 
tions, there  is  both  a  leukocytosis  and  a  disturbed  relation  between  the 
different  forms  of  leukocytes.  Here  the  polymorphonuclear  cells 
are  augmented,  and  in  aggravated  cases  highly  so,  a  change  in  the 
blood  which  indicates  a  gangrenous  process  in  the  appendix.  Bac- 
teria are  frequently  found  in  the  blood,  but  under  such  circumstances 
they  may  or  may  not  be  a  factor  in  the  disease  from  which  the  patient 
suffers. 

Since  the  blood  examinations  and  experiments  made  by  investi- 
gators indicate  that  micro-organisms  can  enter  the  circulation  when 
the  continuity  of  the  mucosa  is  broken,  and  that  when  it  is  not  they 
can  during  digestion  pass  from  the  bile  into  the  chyle,  thence  to  the 
circulation,  one  authorit>-  maintains  that  the  blood  should  be  sterile 
or  contain  but  a  small  number  of  bacteria  during  fasting,  since  the 
lungs  and  other  organs  act  as  a  filter  for  the  micro-organisms.  It 
has  also  been  claimed  that  in  man  bacteria  pass  from  the  intestine 
into  the  blood  during  a  protracted  death  struggle,  especially  the 
colon  bacillus,  which  is  assumed  to-  enter  the  circulation  in  large 
numbers  before  death,  and  to  multiply  preferabh'  in  the  spleen,  the 
bone-marrow,  the  li\'er,  and  the  thyroid  gland. 

Proctoscopic  and  sigmoidoscopic  examinations  enable  one  to 
make  a  jjosiiixe  diagncjsis  ot  paih()l(jgic  conditions  situated  in  the 
upj)er  rectum  and  sigmoid  flexure  which  was  impossible  before  the 
ad\ent  of  the  proctoscope  and  sigmoidoscope.  Force  should  never 
be  used  in  the  introduction  of  these  instruments,  otherwise  there  is 
danger  of  rupturing  the  bowel.  The  author  has  had  one  such  acci- 
dent, and  similar  cases  have  been  reported.  The  rupture  in  most 
instances  occurs  in  the  sigmoid  flexure  between  its  two  fixed  points. 
It  requires  considerable  practice  to  properly  and  painlessly  introduce 
the  proctoscope  or  sigmoidoscope,  and  the  correct  knee-chest  posture 
(Fig.  5)  is  essential  to  secure  the  desired  amount  of  inflation,  except 
when  the  instrument  used  has  a  glass-cap  covering  and  a  bulb  attach- 


44 


EXAMINATION    AND    DIAGNOSIS 


ment   for  inflating,  when    the    patient   may   l)e  placed   in   the  Sims 
position. 

Usually  the  patient  is  placed  in  the  genupectoral  position  (Fig. 
5),  the  proctoscope    ur    siomoidoscope    is   oiled  and  introduced  into 


Fig.  5.— Correct  genupectoral  posture  for  proctoscopy. 

the   rectum,    and    directed   downward    and    forward    until    it    passes 
through   the  anal   canal    (Fig.   6).     It   is  then   pointed   upward   and 


Fig.  6. — Method  of  introducing  the  proctoscope:   First  step 

backward  until  the  promontory  of  the  sacrum  is  reached   (Fig.  7), 
when  it  is  again  directed  downward  and  forward  over  the  upper  rectal 


PROCTOSCOPIC    AND    SIGMOIDOSCOPIC    EXAMINATIONS  45 

valve  and  into  the  sigmoid  flexure  (Fig.  8).     The  obturator  is  then  re- 
moved and  the  air  permitted  to  rush  in  and  dilate  the  bowel.     When 


\ 
Fig.  7. — ^lethod  of  introducing  the  proctoscope:   Second  step. 

this   has  been   accomplished,    the  sigmoid   is  examined,   and   as   the 
instrument  is  slowly  withdrawn  a  perfect  view  of  every  part  of  the 


Fig.  8. — Method  of  introducing  the  proctoscope:   Third  step. 

bowel  can  be  obtained.  In  this  way  one  can  with  accuracy  discover 
any  and  all  pathologic  conditions  within  the  lower  bowel  that  inter- 
fere with  the  evacuations. 


46 


EXAMINATION    AND    DIAGNOSIS 


When  the  air  does  not  dilate  the  sigmoid  flexure,  a  pneumatic 
sigmoidoscope  should  be  introduced,  with  the  obturator  in  place,  until 
the  middle  valve  has  been  passed.  The  obturator  is  then  removed, 
and  the  rectum  and  bowel  higher  up  are  inflated  and  studied  step  by 
step,  by  pressing  the  bulb  from  time  to  time,  as  the  instrument  is ' 
passed  higher  up.  In  this  way  a  splendid  view  is  obtained,  and  any 
obstruction  within  the  rectum  or  sigmoid  may  be  easily  and  accu- 
rately located  and  examined.  For  this  purpose  Sims'  position  is 
the  most  comfortable  one  for  the  patient.  With  ordinary  procto- 
scopes reflected  light  is  employed,  but  with  the  pneumatic  a  small 
lamp   is  placed   inside  or   outside,   at  the  end   of   the   tube,   to  pro- 


Fig,  g. — Laws'  pneumatic  proctosigmoidoscope. 

vide  the  necessary  illumination  (Fig.  9).  These  instruments  come  in 
various  sizes  and  lengths.  Those  most  generally  employed  are  4,  8, 
and  14  inches  (10,  20,  and  35  cm.)  in  length  and  a  little  less  than  i 
inch  (2.5  cm.)  in  diameter. 

Digital  examination  is  the  most  reliable  method  of  detecting  dis- 
ease in  the  lower  bowel,  and  much  valuable  information  can  be  ob- 
tained by  means  of  the  educated  finger  (Fig.  10).  In  this  way  one 
can  easily  and  quickly  diagnose  fissures,  ulcers,  polypi,  cancers,  stric- 
tures, fecal  impaction,  foreign  bodies,  hemorrhoids,  hypertrophy  of 
the  rectal  valves  and  of  the  levator  ani  and  sphincter  muscles, 
thickening  and  rigidity  of  the  bowel  wall,  di\-erticula,  enlargement  of 
the  prostate,  retroflexion  of  the  uterus,  deviated  coccyx,  and  other 


RONTGEX  RAYS  (x-RAYS) 


47 


conditions,  which  alone  or  together  impede  the  feces  in  their  down- 
ward course  or  cause  diarrhea. 

Digital   examination,    properly   executed,    induces   but   little   dis- 
comfort, but  when  the  finger  is  hurriedly  and  carelessly  introduced 


Fig.  lo. — Correct  method  of  digital  examination  with  the  patient  in  the  lithotomy  posture. 


it  causes  much  unnecessary^  suffering.  The  nail  should  be  pared, 
the  finger  oiled  with  some  stiff  lubricant,  such  as  vaselin,  and  passed 
slowly  through  the  anus  with  a  gentle  boring  motion.  When  the 
sphincter  contracts,  a  few- 
seconds  should  be  allowed 
for  it  to  relax;  the  ex- 
amination may  then  be 
continued  by  sweeping  the 
finger  around  the  bowel, 
first  in  one  direction  and 
then  in  another.  The  con- 
dition of  the  sphincter, 
surface  of  the  mucosa, 
prostate  gland,  uterus, 
bladder,  vaginal  septum, 
sacrum,  and  coccyx  ma\' 
in  this  way  be  determined. 

Rectal  Specula. — Since 
the  advent  of  the  procto- 
scope, specula  (Fig.  ii)  are 
rarely  used  for  rectal  ex- 
aminations, because  they  induce  more  suffering  and  do  not  give  as 
good  a  view  of  the  parts  as  tubular  instruments  (proctoscopes). 

Rontgen  Rays   f.r-rays). — Until  recently  radiograms  and  fluoro- 
scopic exaniinaiions  were  regarded  as  diagnostic  novelties  in  so  far 


Fig.  II. — .Author's  examining  speculum. 


48 


EXAMINATION    AND    DIAGNOSIS 


as  they  related  to  affections  of  the  gastro-intestinal  tract,  but  have 
gradually  gained  in  favor,  until  now  they  are  considered  valuable 
diagnostic  aids  and  are  resorted  to  daily,  and  practical  men  do  not 
venture  a  positive  diagnosis  in  diarrhea  or  other  obscure  conditions 
of  the  stomach,  small  intestine,  or  colon  until  they  have  had  ront- 
grams  made,  or  inspected  the  workings  of  the  stomach  or  bowel 
through  the  fluoroscope  following  the  administration  of  bismuth, 
test-meals,  or  injections. 

A'-rays  in  the  hands  of  the  novice  reveal  little  or  nothing  of 
diagnostic  value,  and  are  extremely  dangerous  to  physician  and 
patient  unless  they  are  properly  protected,  which  is  practically  im- 
possible with  the  equipment  found  in  most  offices.  Formerly  the 
author  made  radiograms  and  fluoroscopic  examinations  in  his  oflice, 


i  :.:.  ::. — R..  i:  -'ram  showing  gastric 
Clin  aiures.  sphincter,  fundus,  and  position 
of  the  duodenum  (erect  posture). 


Fig.  13. — Radiogram  showing  relation 
of  the  stomach  and  adjacent  small  intes- 
tine (prone  posture).     (Taken  bj-  Cole). 


but  now  refers  his  patients  for  .v-ray  diagnosis  to  rontgenologists 
who  maintain  a  fully  equipped  .v-ray  laborator\'',  and  the  change 
has  proved  eminently  satisf acton.-,  because  in  this  way  more  accurate 
radiograms  and  fluoroscopic  views  have  been  obtained  with  less  cost 
and  annoyance  to  the  patient  than  occurred  under  the  older  arrange- 
ment. 

Physicians  who  do  not  employ  the  .v-ra\-  in  connection  with  gas- 
tro-intestinal work  are  oblivious  to  its  value,  often  fail  to  make  a 
diagnosis,  and  miss  many  interesting  and  practical  discoveries.  For- 
tification of  the  diagnosis  by  means  of  .v-ray  pictures  in  cases  where 
one  has  almost  arrived  at  definite  conclusions  is  often  most  gratify- 
ing, and  encourages  the  physician,  who  can  at  once  proceed  intelli- 
gently with  hygienic,  medical,  or  physical  therapeutic  measures,  or 
operate  when  necessar\-  with  a  greater  degree  of  confidence.      The 


RONTGKN    RAYS    (:)C-RAYS) 


49 


author  has  had  numerous  ratliograms  made  of  supposedly  normal 
individuals  and  those  suspected  of  having  gastro-intestinal  derange- 
ments, and  these  pictures  indicate  that  the  size,  contour,  and  posi- 
tion of  the  esophagus,  stomach,  duodenum,  small  intestine,  colon, 
sigmoid  flexure,  rectum,  and  the  solid  viscera  are  abnormal  or  dis- 
placed very  much  more  frequently  than  the  profession  believes. 
Viewed  from  the  standpoint  of  anatomy,  it  is  the  exception  rather 
than  the  rule  when  one  obtains  in  healthy  or  sick  individuals  radio- 
grams which  show  all  the  viscera   in    position  and  without  defects. 


SF 


.  OIVERTICULUH 


^~&JL 


Fig.  14. — Radiogram  of  a  diverticulum  located  in  tlie  descending  colon  and  a  dilated 

cecum. 


Consequently,  radiograms  indicate  that  anatomists  have  incorrectly 
described  the  contour  and  position  of  the  organs,  that  they  frequently 
change  their  position  in  healthy  individuals,  or  they  are  often  ab- 
normally small  or  large,  distorted  or  ptotic. 

The  esophagus  can  be  slightly,  and  the  stomacJi  fairl\-  well,  defmed 
and  studied  with  the  aid  of  radiograms  and  fluoroscopic  inspection 
(Fig.  12).  A^-ray  investigation  of  the  small  intestine  and,  more 
particularly,  its  upper  part,  the  duodenum  (Fig.  13),  is  difficult  and 
unsatisfactory  because  the  bismuthized  food  passes  througli  it 
rapidly,  but  when  carefully  taken  excellent  photographs  can  be  ob- 


50 


EXAMINATION    AND    DIAGNOSIS 


tained  of  the  lower  ileum,  indixidual  segments  of  the  colon,  and  the 
sigmoid  flexure  and  rectum,  following  a  two  days'  bismuth  diet  or  fill- 
ing of  the  large  bowel  with  a  bismuth  solution.  It  is  generally 
believed  that  water  injected  into  the  colon  cannot  be  made  to  enter 
the  small  intestine,  but  elsewhere  the  author^  has  given  instances 
of  where  this  has  been  accomplished,  and  more  recently  has  been 
able  to  demonstrate  by  rontgrams  that  copious  colonic  bismuth  in- 
jections do  pass  the  ileocecal  valve  and  enter  the  small  bowel,  and 
his  pictures  indicate  that  this  not  infrequently  occurs,  because  in 
several  radiograms  the  lower  ileum    has    been    made  plainly  visible 


noa ^ 


■^F 


Fig.   15. — Radiogram  of  early  larcinoma  of  the  transverse  colon  without  metastases. 
Successfully  removed  by  operation  (Cole). 


through  bismuthization  in  this  way  in  cases  where  none  of  the  drug 
had  been  administered  by  way  of  the  mouth  (Figs.  14,  15).  In  one  case 
Lane's  kinking  of  the  ileum  in  proximity  to  the  ileocecal  juncture  was 
very  well  shown.  Burke^  has  been  able,  through  radiograms,  to 
demonstrate  an  hour-glass  contraction  of  the  duodenum  incited  by 
two  circular  ulcers,  and  others  have  in  a  few  instances  been  able  to 
photograph    duodenal   distortions.      The   .v-ray   and    radiograms   are 

*  Gant,  Consti})ation  and  Intestinal  Obstruction,  iqio,  pp.  230,  231. 
^  Surgery,  Gynecology,  and  Obstetrics,  191 1. 


RONTGEN    RAYS    (x-RAYS)  5I 

perhaps  the  most  reHable  diagnostic  measures  we  have  for  locating 
metalHc  foreign  bodies,  bismuth  accumulations,  enteroliths,  and  cal- 
culi in  the  alimentary  tract;  defining  esophageal  strictures  and  car- 
diospasm; demonstrating  the  size,  outline,  and  position  of  the  stom- 
ach when  abnormal,  and  the  presence  of  strictures,  tumors,  or  hour- 
glass contraction  within  and  adhesions  which  pull  ujxjn  it;  showing 
the  normal  in  healthy,  and  abnormal  motility  of  the  bowel  in  affec- 
tions of  the  gastro-intestinal  tract,  which  enables  the  observer  to 
determine  the  rapidity  with  which  the  food  passes  through  the  stom- 
ach and  various  segments  of  the  intestine  and  the  lime  it  takes  for 
the  colon  to  empty,  which  varies  from  twenty-four  to  forty-eight  hours. 
This  diagnostic  adjuvant  is  most  valuable  in  clearing  up  obscure 
lesions  affecting  the  colon,  sigmoid,  or  rectum,  since  following  the 
administration  of  a  bismuth  meal  or  injection  it  can  be  photographed 


Fig.  1 6. — This  radiogram  demonstrates  that  it  is  sometimes  impossible  to  introduce 
a  tube  into  the  colon,  even  though  it  is  projected  through  a  sigmoidoscope  already  in 
the  lower  sigmoid  fle.xure. 

to  advantage,  and  existing  abnormalities,  such  as  ptosis  of  one  or  all 
the  colonic  segments,  angulations;  twists,  invaginations,  binding  ad- 
hesions, foreign  bodies,  diverticula,  tumors,  etc.,  located  within  or 
which  invoK'e  them  can  be  shown.  In  this  way  one  can  also  demon- 
strate the  position  of  an  introduced  colon  tube,  and  determine  its 
usefulness  for  high  colonic  flushing,  which  is  doubtful,  since  radio- 
grams indicate  that  the  tube  generally  curls  up  in  the  rectum  or  lower 
sigmoid  (Fig.  16)  except  in  cases  of  colonic  congenital  or  acquired 
dilatation. 

The  fliioroscope  is  useful  in  stud\ing  gastro-intestinal  peristaltic 
waves  and  following  a  bismuth  meal  through  the  stomach,  small 
intestine,  downward  to  the  colon,  and,  to  some  extent,  for  noting 
displacement  of  the  viscera  and  locating  segments  of  gut  wherein 
abnormal  peristalsis  takes  place  in  the  presence  of  strictures;  but  for 
other  purposes  it  is  inferior   to   radiograms  as  a  diagnostic  measure, 


52  EXAMINATION    AND    DIAGNOSIS 

and  should  be  discarded  for  them,  because  of  this  and  the  danger  of 
burning  the  patient,  owing  to  the  lengthy  exposure  required.  Con- 
siderable care  and  patience  are  required  in  obtaining  radiograms  of 
the  viscera,  and  several  pictures  should  be  taken  with  the  patient 
King  upon  the  abdomen,  sides,  back,  and  in  the  erect  posture,  so  that 
changes  in  the  location  and  character  of  the  lesions  and  organs  can  be 
determined  under  varsing  conditions.  Radiograms  of  the  stomach, 
and  particularly  the  colon,  are  often  unsatisfactory'  in  fat  individuals, 
and  such  patients  should  be  placed  in  the  position  which  will  bring  the 
organ  to  be  photographed  nearest  the  plate. 

Physicians  should  not  hesitate  to  have  patients  .v-rayed  by  a  com- 
petent rontgenologist,  because  burning  now  rarely  occurs  since  the 
subject  can  be  well  protected  from  the  rays,  and  the  pictures  are  taken 
with  new  and  powerful  machines  in  from  one  to  ten  seconds. 

The  technic  of  preparing  the  patient  for  radiography  and  fluoro- 
scopic examination  is  not  elaborate,  but  must  be  systematically 
carried  out.  because  when  it  is  not,  fluoroscopic  examinations  are  un- 
satisfacton.-.  will  show  nothing,  and  the  pictures  will  be  imperfect. 
Better  results  are  obtained  when  the  stomach  and  bowel  are  cleared 
of  their  contents  before  the  bismuth  is  administered  by  mouth  or  is 
injected  into  the  colon,  and  to  this  end  it  has  been  the  author's  prac- 
tice to  have  the  patient  fast  before  the  drug  is  consumed  by  mouth, 
and  take  a  dose  of  castor  oil  the  night  before  the  colon  is  to  be  bis- 
muthized  from  below.  After  the  patient  has  been  stripped  to  the 
hips,  and  guiding  markers  have  been  placed  at  the  ensiform  and 
umbilicus,  he  should  be  covered  with  a  sheet,  placed  in  the  proper 
posture  against  the  plate,  and  instructed  to  keep  perfectly  quiet.  Of 
the  various  media  administered  by  mouth  or  injected  into  the  colon 
to  make  the  gastro-intestinal  tract  visible  for  fluoroscopic  examina- 
tion and  -Y-ray  photograph,  bismuth  in  one  form  or  another  has 
proved  the  least  dangerous  and  expensive,  the  most  effective,  and  is 
generally  employed  by  expert  rontgenologists.  At  first  bismuth 
suhnitrate  was  largely  used,  but  in  a  few  instances,  where  it  was  im- 
pure and  contained  arsenic,  unpleasant  or  dangerous  manifestations 
followed  its  administration,  and  because  of  this,  and  the  fact  that  it 
contains  more  of  the  bismuth  element  and  gives  equally  good  results, 
the  suhcarbonate  has  been  substituted  for  it. 

As  a  means  of  bismuthizing  the  stomach,  small  intestine,  and  colon 
from  above  the  author  employs  from  i  to  6  drams  (3-23  gm.)  for  chil- 
dren and  I  to  3  oz.  (30-90  gm.)  of  bismuth  subcarbonate  for  adults, 
administered  in  meat,  gra\y,  butter,  milk,  cream,  beaten  egg,  gruels, 
apple  sauce,  koumiss,  zoolak.  menstruimi  of  acacia,  or  other  media  that 
will  retain  the  chemical  in  suspension  for  the  necessan.-  length  of  time. 
When  the  drug  is  used  in  the  form  of  an  injection  for  colonic  work  it 
may  be  successfully  employed  suspended  in  acacia  or  admixed  with 
fullers'  earth  and  water  in  the  following  proportions,  viz.:  Bismuth 
subcarb..  ,^ij;  fullers'  earth,  3iv;  water,  Oij.  Almost  any  amount 
of  bismuth  subcarbonate  may  be  used  in  the  solution  without  doing 


ROXTGEN    RAYS    (.r-RAYS)  53 

harm,  since  absorption  in  liie  large  bowel  is  not  active;  but  to  avoid 
danger  from  this  source  the  author  makes  a  practice  of  washing  out 
the  bowel  through  the  sigmoidoscope  or  a  return-flow  colon  tube  when 
fluoroscopic  examinations  have  been  completed  and  i:)ictures  taken. 
A  fjuart  (liter)  of  the  solution  is  sufficient  when  the  sigmoid  is  to  l)e  in- 
vestigated ;  2  quarts  (liters)  are  necessary  for  the  transverse  colon,  and  3 
quarts  (liters)  are  required  when  the  entire  colon  is  to  be  inspected  or 
photographed,  and  when  it  is  to  be  determined  whether  or  not  the 
bismuth  enters  the  low^'r  ileum.  The  advisability  of  {photographing 
the  patient  while  in  different  postures,  to  determine  if  the  viscera  or 
lesions  change  their  position,  has  already  been  mentioned.  This 
practice  is  also  interesting,  because  the  level  to  which  the  bismuth 
settles  in  the  hollow  viscera  is  plainly  shown  when  the  picture  is  made 
with  the  patient  standing  against  the  plate. 

Radiograms  and  fluoroscopic  examinations  are  rather  impractical 
for  general  use  because  of  the  expense  they  incur,  the  time  and  difficulty 
encountered  in  properly  preparing  the  patient,  and  because  the  pictures 
are  not  always  sufficiently  distinct  to  enable  the  physician  to  complete 
the  diagnosis.  Radiographic  plates  and  prints  from  them  should 
be  studied  closely  because  they  are  often  difficult  to  interpret,  and  re- 
reading them  frequently  helps  to  define  lesions  unobserved  at  the 
first  inspection.  The  novice  should  early  learn  to  analyze  the  lights 
and  shadows  and  to  closely  distinguish  clear  spots,  which  indicate 
accumulations  of  air  or  gas,  from  darker  areas,  which  show  that  the 
viscera  has  been  bisinuthized  at  such  points.  In  a  few  instances  the 
author  has  obtained  radiograms  following  inflation  of  the  colon  with 
gas  and  air  independent  of  bismuthization,  wherein  certain  segments 
of  the  healthy  and  diseased  bowel  were  distinctly  visible  or  the  posi- 
tion, size,  and  the  entire  colon  could  be  defined.  Slight  or  partial 
inflation  is  sometimes  useful  in  conjunction  with  bismuth  because  it 
distends  the  gut,  lifts  it  upward,  straightens  out  angulations  or  kinks, 
and  brings  intestinal  neoplasms  nearer  the  surface  or  displaces  those 
pressing  upon  the  gut;  but,  for  general  radiographic  purposes,  filling 
the  gut  with  air  or  gas  is  not  to  be  compared  with  either  of  the  methods 
of  bismuthizing  the  large  bowel  mentioned  above. 

Einhorn's  test  beads,  food-carrying  cups,  duodenal  tubes,  obturators, 
and  other  diagnostic  instruments  are  frequently  serviceable  in  help- 
ing one  to  arrive  at  a  correct  diagnosis  in  confusing  cases  of  gastro- 
intestinal affection,  and  in  determining  which  segment  of  the  alimen- 
tary tract  is  not  functionating  properly. 


CHAPTER   III 

ORGANIC  DISEASES,  DIARRHEA   IN 

OCULAR,  BUCCAL.  DENTAL.  NASOPHARYNGEAL.  THYROID  GLAND, 
LIVER,  PANCREAS,  KIDNEY.  SUPRARENAL,  GENITAL.  URINARY, 
SKIN,  BONE 

Eye  Diseases,  Diarrhea  in. — Eye  abnormalities,  such  as  muscle 
strain,  errors  in  refraction,  and  the  disturbances  caused  by  over- 
work from  study,  typewriting,  bookkeeping,  and  the  like,  requiring 
close  application  of  the  eyes,  have  been  known  to  lead  to  diarrhea 
through  making  the  sufferer  extremely  ner\-ous,  a  manifestation  often 
complicated  by  frequent  watery  movements  containing  neither  pus, 
blood,  nor  mucus.  More  often  profuse  diarrhea,  through  its  deplet- 
ing effect  and  loss  of  the  body  fluid,  leads,  owing  to  weakness  and 
lowered  resistance,  to  certain  serious  ocular  disturbances.  Zimmer- 
mann  has  reported  an  interesting  case  of  blindness  and  atrophy  of  the 
optic  nerve  following  severe  diarrhea,  and  Knies  has  pointed  out  that 
a  profuse  diarrhea  may  give  rise  to  xerosis  of  the  conjunctiva  and 
cornea  in  children  precisely  as  cholera  in  adults  through  desiccation 
and  subsequent  infection,  and  says  that  the  micro-organisms  do  not 
seem  to  develop  very  rapidly  in  the  dry  and  cold  cornea,  and  the  proc- 
ess is  not  so  rapidly  progressive  as  in  other  forms  of  infectious  kera- 
titis at  that  age.  Generally,  but  not  invariably,  the  onset  of  xerotic 
keratitis  in  cholera  infantum  is  the  precursor  of  death,  which,  as  a 
rule,  occurs  prior  to  perforation  of  the  cornea,  which  otherwise  fol- 
lows. For  obvious  reasons  the  disease  is  almost  invariably  bilateral, 
although  the  two  eyes  are  often  not  affected  to  the  same  degree. 
Here  the  intestinal  disease,  as  such,  exerts  a  beneficent  effect  upon  the 
development  of  the  trouble  in  the  eye,  because  the  enormous  loss  of 
fluid  in  profuse  diarrhea  facilitates  the  drying  out  of  unsheltered 
regions.  Evidently  there  exists  at  the  same  time  a  sort  of  ptomain 
anesthesia,  which  causes  the  lack  of  sensibility  in  the  cornea  and 
the  imperfect  winking  of  the  eyelids. 

Treatment  of  diarrhea  dependent  upon  strain  or  other  eye  affec- 
tions which  excite  a  neurotic  condition  consists,  first,  in  correcting 
the  ocular  disturbance,  and  then  treating  the  loose  movements  after 
the  plan  outlined  in  the  chapter  devoted  to  Neuropathic  Diarrheas. 
On  the  contrary,  when  the  ocular  manifestation  is  a  sequel  of  pro- 
fuse diarrhea,  the  frequent  evacuations,  irrespective  of  the  cause, 
must  be  stopped ;  othersvise  the  therapeutic  measures  directed  against 
the  eye  disease  will  fail. 

Mouth  Diseases,  Diarrhea  in. — This  type  of  diarrhea  may  be  in- 
cited by  the  swallowing  of  pathogenic  bacteria  in  certain  diseases 
involving  the  teeth  or  buccal  mucous  membrane. 

54 


NASOPHARVXGE.VL    DISEASES,    DIARRHEA    IN  55 

Patients  whose  molar  teeth  are  tender,  decayed,  or  absent  rarely 
divide  the  food  as  finch'  as  it  should  be,  because  the  grinding  is  ac- 
complished with  teeth  unsuitable  for  the  purpose,  and  in  consequence 
it  is  deposited  in  the  stomach  in  lumps  which  arc  not  readily  digested 
because  of  their  size  and  the  difficulty  of  the  secretions  saturating 
them. 

Diarrhea  from  buccal  causes  most  often  results  from  the  swallow- 
ing of  germs  which  have  accumulated  upon  the  back  of  the  tongue, 
between,  or  in  cavities  of,  the  teeth,  and  on  artificial  plates  and  bridges 
where  the  patient  does  not  properly  cleanse  them.  Again,  the  loose 
movements  may  be  attributed  to  unclean  syphilitic  or  other  ulcers 
of  the  mouth,  the  discharge  coming  from  dental  abscesses  (owing  to 
the  action  of  the  bacteria  contained  in  the  unhealthy  secretions)  and 
the  swallowing  of  considerable  saliva,  which  may  cause  dyspepsia. 

The  diagnosis  can  usually  be  readily  made  by  examining  the  mouth 
for  and  detecting  the  causative  factors  already  mentioned. 

The  treatment,  which  is  obvious,  consists  in  frequent  cleansing  of 
the  roughened  portion  of  the  tongue,  the  teeth,  cavities  within  them, 
plates,  and  bridges,  as  well  as  ulcers  and  abscess  pockets.  Teeth 
which  are  decayed  beyond  saving,  and  those  which  are  detached  from 
the  gums  or  cause  frequent  irritation,  should  be  drawn  and  the  wound 
treated  until  healed,  and  operative  interference  is  indicated  when 
there  is  an  acute  abscess,  chronic  discharge  from  necrosed  bone  or 
root  of  a  tooth.  When  removing  the  source  of  the  trouble  does  not 
cure  indigestion  and  diarrhea,  they  should  be  treated  symptomatically. 

Nasopharyngeal  Diseases,  Diarrhea  in. — Sufficient  cases  ha\'e 
been  recorded  in  the  literature  to  demonstrate  that  under  favorable 
conditions  nasopharyngeal  affections  are  capable,  directly  or  reflexly, 
of  producing  gastro-intestinal  disturbance  and  diarrhea,  and  that 
disease  of  the  stomach  and  intestine  may  at  times  affect  the  nose 
and  throat. 

In  discussing  these  cases  one  authorit\"  says  that  thu  interdepend- 
ence of  the  respiratory  apparatus  and  gastro-intestinal  tract  is  a 
vicious  circle,  and  that  nose  and  throat  troubles  can  react  upon  the 
gastro-intestinal  system  or  vice  versa. 

Nearly  all  practitioners  have  observed  vomiting  and,  frequently, 
loose  movements  to  follow  acute  conditions  of  the  nasopharynx, 
accompanied  by  a  rise  of  temperature,  edema  of  the  mucosa,  and  pro- 
longed spasms  of  coughing  excited  by  a  tickling  in  the  throat  or 
reflex  disturbance.  In  other  cases,  as  in  coryza  and  chronic  catar- 
rhal affections,  the  same  or  more  marked  stomach  and  bowel  symp- 
toms may  result  from  the  almost  constant  hawking  and  swallowing 
of  large  quantities  of  mucus  which  is  often  virulenth-  infectious. 
Again,  the  accessory  sinuses  draining  into  the  nasopharynx  are  fre- 
quently the  seat  of  fetid  abscesses,  as  are  also  the  tonsils  and  phar\nx, 
which  spontaneously  or  following  operation  discharge  into  the 
throat;  pus  seething  in  pathogenic  bacteria  is  swallowed  in  consid- 
erable amounts,  setting  up  an  irritative  or  infective  gastro-enteritis 


56  ORGANIC    DISEASES,    DIARRHEA    IN 

with  increased  evacuations.  Evidence  to  this  end  has  been  obtained 
in  finding  of  the  same  bacteria  in  the  secretions  taken  from  the  naso- 
phar\nx,  stomach,  and  intestines.  ' 

Children  atflicted  with  adenoids  greatly  improve  as  regards  appe- 
tite, digestion,  intestinal  ailments,  and  general  metabolism  following 
the  removal  of  adenoids,  and  this,  as  White  has  suggested,  is  prob- 
ably due  as  much  to  the  stopping  of  swallowing  unhealthy  secretions 
as  it  is  to  benefit  of  the  breathing  apparatus.  Arguing  from  this, 
there  is  reason  to  believe  the  other  above-mentioned  conditions  can 
produce  like  disturbances  or  worse  when  virulent  secretions  reach 
the  gastro-intestinal  tract. 

It  is  interesting  to  note,  in  this  connection,  the  case  of  Aronsohn. 
where  a  patient  had  an  immediate  desire  to  evacuate  the  bowel  fol- 
lowing cocain  applications  to  the  nose  in  the  treatment  of  asthma 
from  which  she  had  suffered  six  years. 

To  show  the  reverse  state,  Cotifin  has  called  attention  to  the  fol- 
lowing ways  in  which  disease  of  the  upper  air-passages  may  be  pro- 
duced or  affected  by  those  of  the  gastro-intestinal  tract : 

(i)  Mechanically,  by  constipation,  which  causes  slowed  circula- 
tion, congested  condition  of  the  parts,  and  a  consequently  changed 
secretion. 

(2)  By  Reflex  Actio?!. — Many  interesting  conditions  are  seen  in 
the  upper  air-passages  due  to  vasomotor  changes  and  glandular  activ- 
ities, which  are  apparently  due  to  reflex  actions  having  their  stimuli 
in  the  disordered  condition  of  the  gastro-intestinal  tract. 

(3)  Toxemia,  meaning  those  conditions  found  in  the  upper  air- 
passages  which  are  caused  by  toxic  substances  found  in  the  blood  as 
the  result  of  imperfect  digestion  and  disturbed  metabolism. 

The  treatment  of  nasophar\-ngeal  diarrhea  depends  upon  the  nature 
of  the  disease  or  lesion  causing  local  irritation,  reflex  disturbance,  and 
the  formation  of  mucus  or  pus,  the  indication  for  the  handling  of  which 
the  reader  is  referred  for  a  detailed  description  to  the  standard  works 
on  the  nose  and  throat. 

It  is  not  necessar\"  to  do  more  here  than  briefly  state  that  acute 
and  chronic  abscesses  should  be  reached,  curetted,  and  drained  at 
the  earliest  possible  moment.  Hypersensitive  areas,  ulcers,  and  in- 
flamed mucosa  should  be  relieved  by  sprays,  topical  applications,  and 
internal  medication,  the  latter  being  particularly  serviceable  when 
the  patient  is  neurotic.  The  most  important  features  of  the  treat- 
ment, however,  is  to  see  that  the  nasopharynx  is  frequently  cleansed, 
the  patient  educated  to  cough  up  and  expectorate  and  not  to  swallow 
the  obnoxious  secretions,  and  to  remove  the  adenoids. 

Thyroid  Diseases  Exophthalmic  Goiter  i,  Diarrhea  in. — Diar- 
rhea constitutes  one  of  the  most  frequent  and  annoying  manifesta- 
tions of  exophthalmic  goiter,  and  it  may  usher  in  the  disease  or  ap- 
pear at  any  time  and  be  transitor\-.  periodic,  or  remain  permanently 
and  add  greatly  to  the  sutt'ering  of  the  patient,  and  sometimes  the 
stools  escape  involuntarily.     Again,  the  loose  movements  may  be  in- 


THYROID    DISEASES    (EXOPHTHALMIC    GOITER),    DIARRHEA    IX        57 

dependent  and  of  sudden  onset  or  appear  at  the  crises,  when  tachy- 
cardia, ocular  and  other  manifestations  are  most  pronounced,  both 
in  the  incipient  and  later  stai^es  of  the  disease. 

The  evacuations  are  fluid,  bile  tinted,  and  contain  whole  peas, 
grains  of  corn,  pieces  of  tomato,  and  other  food  remnants  a  few  hours 
after  they  have  been  eaten,  showing  that  digestion  is  impaired  and 
peristalsis  accelerated.  Here,  as  in  neurotic  diarrhea,  the  patient 
suffers  from  nocturnal  diarrhea;  that  is,  has  a  number  of  passages  in 
the  early  morning  which  rapidly  follow  each  other. 

Exophthalmic  goiter  subjects  frequently  have  a  ravenous  appe- 
tite, eat  much  more  than  they  can  digest,  and  this  sooner  or  later  leads 
to  a  true  enterocolitis,  which  is  evidenced  by  the  presence  of  mucus 
in  the  stools.  This  type  of  loose  movements  is  similar  to  that  induced 
by  diminished  pancreatic  secretion  described  elsewhere.  Balint 
and  Molnar  have  studied  this  condition  carefully,  and  conclude  that 
instead  of  there  being  an  insufficiency  there  is  an  increase  of  pan- 
creatic secretion  and  perhaps  of  other  juices.  They  say  that  it  can- 
not be  altogether  denied  that  this  generally  increased  secretion  is 
possibly  parallel  to  the  overproduction  of  a  peristaltic  "hormone"; 
this  would  serve  to  explain  the  azotorrhea  and  steatorrhea  in  the 
presence  of  abundant  ferment.  The  specific  action  of  the  thyroid 
gland  in  these  conditions  seems  to  be  supported  by  the  observation 
that  myxedematous  patients  usually  suffer  from  rebellious  obstipa- 
tion. In  a  case  under  the  author's  observation,  concerning  a  woman 
with  myxedema,  the  otherwise  obstinate  obstipation  was  at  once 
replaced  by  regular  stools,  even  by  diarrhea,  when  the  patient  was 
given  thyroid  tablets;  vice  versa,  the  obstipation  returned  as  soon  as 
the  thyroid  tablets  were  omitted. 

It  is  furthermore  noteworthy  that  the  determination  of  the  dias- 
tase in  the  feces  may  render  very  useful  service  in  the  diagnosis  of 
the  loss  of  pancreatic  secretion. 

In  acute  Basedow's  disease  the  patient  also  complains  of  nausea 
and  incessant  vomiting  in  addition  to  the  diarrhea  and  other  typical 
symptoms. 

The  diagnosis  of  exophthalmic  goiter  diarrhea  is  difficult  or  im- 
possible where  this  condition  ushers  in  the  disease,  but  later,  when 
the  patient,  in  addition,  begins  to  suffer  from  tachycardia,  muscular 
trembling,  exophthalmos,  and  enlargement  of  the  gland,  there  is  no 
excuse  for  a  mistaken  diagnosis. 

The  treatment  should  be  non-operative  or  surgical,  according  to 
the  condition  of  the  patient  when  seen.  In  the  incipient  stages  he 
can  usually  be  benefited  by  changing  his  en\ironment  and  sending 
him  to  the  mountains,  because  in  this  way  he  gets  rid  of  unpleasant 
companions,  arduous  indoor  occupations  and  worries,  and.  in  addition, 
has  the  benefit  of  plenty  of  fresh  air  and  the  soothing  effect  of  eleva- 
tion (3500  feet)  upon  the  nerxes  and  circulatory  system.  Patients 
who  do  not  do  well  and  those  that  are  further  advanced  should  be 
given  the  benefit  of  the  rest  cure  and  a  course  of  treatment,  includ- 


58  ORGANIC    DISEASES,    DIARRHEA    IN 

ing   hydrotherapy,   massage,  electricity,    exercise,    and    vibration    to 
improve  their  general  condition  and  quiet  the  ner\es. 

Generally,  medical  agents  are  useful  in  the  symptomatic  treatment, 
but  have  very  little  curative  effect,  though  many  remedies  have  been 
suggested  for  the  purpose.  Anders  reports  4  cases  cured,  2  by  the 
use  of  sodium  salicylate  (gr.  x — 0.60 — four  times  a  day),  and  2  by  the 
following  combination : 

I^.     Ext.  digitalis gr.  iv  (0.25); 

Ext.  ergotae 3s5  (2.0); 

Strychnine  sulph gr.  ss  (0.03) ; 

Ferri  arsenias gr-  ij  (o.i 2). — M. 

Ft.  capsulas  No.  xxiv. 
Sig. — One  t.  i.  d.  after  meals. 

Improvement  has  also  been  known  to  follow  the  bromate  of  quinin, 
thyroidin.  veratrum  viride,  aconite,  belladonna,  the  glycerophosphate 
of  sodium,  and  lecithin  in  conjunction  with  a  milk  diet.  Favorable 
results  have  also  followed  the  administration  of  the  extract  of  the 
suprarenal  gland,  the  cytotoxic  serum  of  Rogers  when  the  patient 
suffers  from  toxemia  and  the  3C-ray. 

The  operative  treatment  of  exophthalmic  goiter  is  more  satisfactory 
than  formerly,  owing  to  improved  technic,  but  the  mortality  and  per- 
manent results  are  still  disappointing.  In  fact,  the  value  of  surgery 
and  the  best  procedure  to  employ  in  these  cases  is  difficult  to  decide, 
because  a  considerable  number  of  cures  and  failures  ha\e  followed 
partial  thyroidectomy,  resection  of  the  sympathetic  ner\e.  and  tying 
of  the  nutrient  blood-vessels. 

For  those  especially  interested  in  the  treatment  of  exophthalmic 
goiter,  comprehensive  statistics  are  now  to  be  had  in  the  current 
literature  covering  the  medicinal,  serum,  and  surgical  treatment  of 
this  affection. 

The  diarrhea  usually  ceases  with  the  reduction  of  the  gland,  but 
may  persist  for  a  time  thereafter,  owing  to  the  irritable  state  of  the 
bowel  or  catarrhal  condition  which  has  been  brought  about.  When 
during  or  following  the  treatment  directed  against  the  thyroidism 
the  movements  become  very  frequent,  painful,  and  exhausting,  opium 
in  2"gr.  (0.03)  doses  or  morphin  in  smaller  amounts,  combined  with 
an  astringent  or  an  antiseptic,  should  be  administered  sufficiently 
often  to  reduce  the  number  of  evacuations  and  secure  for  the  patient 
the  necessary-  comfort  and  rest. 

Liver  Diseases,  Diarrhea  in. — Diarrheal  disturbances  are  encoun- 
tered with  comparative  frequency  in  certain  disorders  of  the  liver, 
gall-bladder,  and  bile-ducts,  particularly  in  nervous  individuals  so 
afflicted,  and  for  some  unaccountable  reason  the  increased  movements 
usually  take  place  shortly  after  eating  and  are  aggravated  by  dark 
meat.  This  type  of  diarrhea  is  not  so  difficult  to  diagnose  when  there 
is  marked  derangement  of  the  liver  or  its  passages  are  blocked,  but 
in  less  severe  cases  it  is  frequently  impossible  to  differentiate  between 
it  and  the  prandial  diarrhea  of  Linossier,  which,  because  of  the  prom- 


LIVER    DISEASES,    DIARRHEA    IN  59 

incnce  of  the  nervous  nianiteslalions  associated  with  it,  is  described 
by  the  writer  in  the  chapter  devoted  to  Nervous  Diarrheas. 

This  form  of  hepatic  cUarrhea  results  from  the  considerable  ac- 
cumulation and  retention  of  bile  which  is  eventually  emptied  into  the 
bowel,  and  makes  up  all  or  a  considerable  proportion  of  the  evacua- 
tions when  admixed  with  the  feces.  Both  patient  and  intestine  are 
already  in  a  state  of  nervous  irritability,  and  the  sudden  discharge 
of  so  much  bile  into  the  sensitive  bowel  ser\'es  directly  to  stimulate 
the  mucous  glands  to  activity  and  the  gut  to  abnormal  i)eristalsis 
through  reflex  action. 

Malignant  and  non-malignant  growths,  gall-stones,  catarrhal 
inflammation,  or  other  disease  which  leads  to  an  obstruction  of  the 
gall-bladder,  biliary  passage,  or  both,  usually  induces  constipation, 
but  in  aggravated  cases  persistent  diarrhea  results,  and  is  due  to  the 
toxic  effect  of  the  absorbed  bile  upon  the  nervous  apparatus  and 
constitution,  and  prevention  of  the  bile  from  reaching  the  intestine 
to  participate  in  the  fermentation  and  putrefaction  going  on  within 
it.  Owing  to  the  absence  of  bile  and  its  stimulating  effect  upon  pan- 
creatic secretion,  intestinal  indigestion  prevails,  and  this,  together 
with  the  abnormal  increase  of  pathogenic  bacteria  and  their  toxins, 
resulting  from  a  lack  of  the  bactericidal  influence  of  the  bile,  leads  to 
the  accumulation  of  irritants  within  the  gut  and  diarrhea  because  of 
the  attempts  on  the  part  of  the  bowel  to  expel  them. 

The  writer  has  known  gall-stones  to  incite  diarrhea,  both  through 
their  irritative  effect  upon  the  mucosa  in  their  downward  course  and 
by  blocking  the  intestine  and  setting  up  an  obstructive  diarrhea. 

Diarrhea  due  to  inflammatory  or  ulcerative  lesions  of  the  intes- 
tine may  precede  or  complicate  hepatic  disease,  but  under  all  cir- 
cumstances is  aggravated  when  the  bile  pours  over  the  lesions  in 
abnormal  amounts  or  is  deficient  and  indigestion  prevails. 

Loose  movements  may  be  induced  by  icterus  {jaundice),  however 
produced,  but  is  not  an  important  manifestation  except  under  the 
above-named  conditions. 

The  various  forms  of  cirrhosis  at  times  cause  diarrhea,  and  it  is 
occasionalh-  very  aggravating  in  alcoholic  subjects,  due  largely  to 
the  markedly  congested  state  of  the  gastro-intestinal  mucosa  in  these 
cases. 

The  disturbed  portal  circulation  in  this  disease  manifests  itself 
1)\-  tlie  congesti\e  hyperemia  of  the  digestive  tract,  which  in  the 
later  stages  of  atrophic  hepatic  cirrhosis  may  lead  to  increased  digest- 
ive disturbances,  vomiting,  diarrhea,  and  sometimes  blood  in  the 
stools. 

Symptoms  and  Diagnosis.— The  symptom-complex  varies  in  accord- 
ance with  the  nature  of  the  hepatic  disturbance.  In  the  obstructive 
types  there  is  jaundice  and  sensitiveness  of  the  gastro-intestinal  tract 
because  of  its  congested  state,  the  stools  contain  lumps  of  fat  or  glis- 
tening globules,  and  they,  with  expelled  flatus,  are  very  offensive,  and, 
owing  to  the  lack  of  bile,  are  ash  or  clay  colored,  and  are  of  a  dark- 


6o  ORGANIC    DISEASES,    DIARRHEA    IN 

brown  or  greenish   color  when  examined  shortly  after  relief  of  the 
obstruction  and  emptying  into  the  bowel  of  bile  in  large  quantities. 

The  movements  in  this  type  of  diarrhea  do  not  occur  with  great 
frequency  (four  to  five  times  daily),  are  more  apt  to  be  mushy  or 
pasty  than  of  a  waters'  consistence,  and  are  usually  preceded  b}'  dis- 
comfort or  severe  pain,  fulness,  and  heaviness  in  the  epigastrium. 

The  nature  of  the  loose  mo\"ements  may  be  suspected  both  in  the 
absence  of  and  when  the  evacuations  are  composed  completely  or 
almost  entirely  of  bile. 

Treatment. — Since  the  majority  of  hepatic  diarrheas  follow  block- 
ing of  the  biliary  flow,  the  most  rational  method  of  procedure,  par- 
ticularly in  urgent  cases,  is  to  explore  the  suspected  region  and  re- 
move the  tumor,  calculi,  or  the  obstruction  causing  the  trouble, 
except  when  due  to  a  marked  catarrhal  state  of  the  bile-passages, 
when  temporary  drainage  may  in  suitable  cases  be  instituted.  In 
the  latter,  and  in  cases  where  there  is  no  occasion  to  hurry,  an  attempt 
should  be  made  to  correct  the  difftculty  with  the  aid  of  medicinal  and 
hygienic  measures. 

It  requires  a  considerable  time  to  overcome  a  catarrhal  inflamma- 
tion which  has  attained  headway  enough  to  partially  or  completely 
obstruct  the  flow  of  bile,  but  in  favorable  instances  relief  is  to  be  had 
from  outdoor  exercise,  bland,  nourishing  diet,  copious  water  drinking, 
hydrotherapy,  gentle  or  friction  massage,  nightly  application  of  a 
cold  girdle,  or,  in  acute  attacks,  hot  applications,  free  drinking  of 
Vichy  and  other  alkaline  mineral  waters,  and  by  having  the  patient 
take  antiseptics  in  liberal  doses  along  with  several  ounces  of  olive  oil 
twice  daily. 

When  the  liver  is  cirrhotic  the  diet  should  be  regulated,  and  con- 
sists largely  of  bland,  non-irritating  foods,  medicants,  such  as  bis- 
muth, charcoal,  magnesia,  and  other  remedies  known  to  have  a  sooth- 
ing effect  upon  an  irritable  mucosa,  should  be  administered,  and  when 
the  bowel  involvement  extends  low  down  this  treatment  should  be 
reinforced  by  intestinal  irrigations,  using  mineral  oil  and  bismuth 
or  weak  solutions  of  boric  acid,  icbthyol,  or  permanganate  of  potas- 
sium. 

In  all  forms  of  hepatic  diarrhea  where  the  movements  are  excessive, 
frequent,  and  irritating,  or  the  patient  suffers  severely  from  pain  in- 
cident to  cramps  or  the  passage  of  biliary  calculi,  morphin  or,  pre- 
ferably, opium,  gr.  h  (0.03),  and  belladonna,  gr.  \  (0.015),  should  be 
prescribed  to  control  the  movements,  relieve  suffering  and  entero- 
spasm,  and  cause  a  relaxation  of  the  abdominal  musculature. 

Pancreatic  Diseases  (Diarrhea  Adiposa),  Diarrhea  in. — This  t\pe 
of  loose  movements  may  result  from  duodenal  disease,  obstruction 
to  the  bile-passages,  pancreatic  affections  (pancreatitis  and  cancer), 
cysts,  or  obstruction  to  the  ducts,  as  above  indicated;  it  occurs  in 
febrile  diseases  of  children;  ingestion  of  an  overabundance  of  oil, 
butter,  cream,  or  other  fatty  medicaments  or  foods;  from  digestive 
disturbances  which  interfere  or  prevent  the  splitting  up  or  absorption 


PANCREATIC    DISEASES    (DIARRHEA    ADIPOSA),    DIARRHEA    IX        6l 

of  the  fatty  elements  of  the  chNnie,  or  uicreased  peristalsis  whieh 
hurries  them  throut;h  the  intestine;  and,  finalK-,  1)\-  oblileration  of 
the  chyle  vessels. 

In  addition  to  diabetes  mellitus,  the  character  and  frequency  of 
the  evacuations  are  materially  changed  in  nearly  all  other  pancreatic 
affections,  and  are  attributed  by  some  to  the  diminished  alkalinity  of 
the  ch\nie.  but  Rathery  believes  that  the  food  is  improperly  digested 
and  excites  peristalsis  both  by  the  quantity  and  quality  of  the  intes- 
tinal contents,  and  that  the  suppression  of  the  pancreatic  juice  causes 
an  increase  in  the  watery  and  a  diminution  in  the  weight  of  the  dry 
food  substances  referable  to  exaggerated  motility  of  the  intestine. 

Physiologists  have  for  a  long  time  taught  that  the  bile  and  pan- 
creatic fluids  largely  control  the  digestion  and  absorption  of  fats,  and 
recentlv  an  abundance  of  evidence  has  been  adduced,  through  opera- 
tion, experiments,  and  examination  of  the  feces,  to  show  that  any 
obstructive  or  other  disease  which  extensively  involves  the  duodenum, 
gall-bladder,  pancreas,  or  the  ducts  leading  to  the  small  lx)wel  may 
cause  fatt\-  diarrhea. 

Ehrstroem  has  reported  a  most  interesting  case  of  fat  diarrhea 
which  resulted  from  obliteration  of  the  chyle  vessels  at  the  mesenteric 
root. 

Occasionally  children  afflicted  with  chronic  intestinal  catarrh 
suffer  from  an  unusual  amount  of  fat  in  the  evacuations,  under  which 
circumstances  the  condition  is  designated  as  diarrhea  adiposa,  a  mani- 
festation which  has  received  attention  at  the  hands  of  Demme  and 
Eichhorst.  Here  the  stools  have  a  fetid  odor,  arising  from  the  fatty 
acids,  an  oily  look,  whitish  or  yellowish  color,  a  pultaceous  consist- 
ence, and  which,  according  to  Biedert,  when  mixed  with  water,  mi- 
croscopically show  fat  droplets  beside  and  above  each  other,  whereas 
normally  they  are  few  and  isolated.  The  fat  contents  determined 
b\-  extraction  of  dried  feces  with  ether  in  healthy  infants  showed  3.8 
to  20.3  per  cent.,  while  in  those  afflicted  with  fatty  diarrhea  the 
percentage  varied  from  41.17  to  67  per  cent,  of  fats. 

Examination  of  the  stools  is  most  important  in  these  cases  be- 
cause there  is  steatorrhea;  they  contain  an  abnormal  amount  of  fat. 
which  is  sometimes  macroscopically  \isible  in  the  form  of  glistening 
droplets,  which,  together  with  the  pasty,  clay-like  appearance  of  the 
feces,  is  characteristic  of  the  condition. 

Treatment  of  Pancreatic  and  Fatty  Diarrhea. — Since  pancreatic 
diarrhea  results  from  disease  within  the  organ,  or  more  freciuently  to 
occlusion  of  its  duct,  nothing  short  of  surgical  intervention  otters  any 
hope  of  a  permanent  cure,  and  the  operation  must  be  selected  accord- 
ing to  indications,  but  preceding  and  following  correction  or  improve- 
ment of  the  trouble,  and  also  in  fatty  diarrheas  from  other  sources 
the  diet  should  be  regulated,  fats  being  restricted  and  the  patient 
given  a  supportive  treatment.  Surgery  gives  the  best  results  in  fatty 
diarrhea  dependent  upon  affections  of  the  gall-bladder,  bile-ducts, 
or  duodenal  obstruction. 


62  ORGANIC    DISEASES,    DIARRHEA    IN 

When  due  to  a  catarrhal  duodenitis,  less  radical  measures,  such  as 
a  non-irritative  and  non-fatty  diet,  the  administration  of  saline  laxa- 
tives, antiseptic  and  antidiarrheal  remedies,  together  with  colonic 
flushings,  usually  suffice  to  diminish  the  oily  constituents  of  the  feces 
and  lessen  congestion  of  the  intestinal  mucosa.  In  some  instances 
patients  suffering  from  fatty  diarrhea  require  symptomatic  treatment, 
and  when,  in  children,  it  is  due  to  febrile  disturbances,  errors  in  diet, 
or  imperfect  digestion,  routine  treatment  is  impracticable,  and  thera- 
peutic measures  should  be  instituted  which  will  correct  or  remove  the 
direct  or  indirect  factor  responsible  for  the  diarrhea,  afterward  treat- 
ing the  bowel  locally  when  necessary. 

Kidney  Diseases,  Diarrhea  in. — Diarrhea  not  infrequently  com- 
plicates organic  and  functional  disturbances  of  the  kidneys.  The 
frequency  of  the  movements  may  be  slightly  accelerated  in  one  case 
or  manifold  in  another,  and  the  diarrhea  may  occur  but  once  and  be 
of  short  duration,  periodic  or  persistent,  and  continue  until  the  kid- 
ney trouble  has  ended  fatally  or  been  relieved. 

Chronic  Nephritis,  Diarrhea  in. — Mackey  has  reported  2  cases  of 
chronic  nephritis,  in  both  of  which  the  bowel  was  found  extensively 
ulcerated  and  the  patient  suffered  severely  from  intestinal  hemor- 
rhages. Perforation  occurred  in  one,  and  Mackey  suggests  that 
increased  blood-pressure  in  this  class  of  cases  leads  to  hemorrhagic 
points  which  later  become  ulcers  through  the  influence  of  bacteria. 
Such  lesions,  in  turn,  increase  peristalsis  and  cause  diarrhea. 

In  some  instances  diarrhea  is  probably  the  result  of  a  co-existing 
gastrogenic  disturbance  or  an  enterocolitis,  under  which  circumstances 
the  movements  bear  a  direct  relation  to  the  number  and  extent  of 
the  lesions,  and  contain  mucus,  pus,  or  blood  alone  or  admixed. 
Diarrhea  caused  by  alTections  of  the  kidney  is  probably  due  to  sec- 
ondary derangement  of  the  central  nervous  system  or  to  the  excre- 
tion into  the  bowel  of  irritating  toxins,  the  latter  being  the  most  im- 
portant etiologic  factor,  as  evidenced  by  the  fact  that  usually  the 
frequent  evacuations  occur  periodically  and  simultaneously  with  the 
exacerbations  of  the  nephritic  condition.  At  such  times  the  move- 
ments are  copious,  very  fluid,  have  an  ammoniac  odor,  and  may  or 
may  not  be  discolored,  accordingly  as  they  contain  bile  or  blood. 

Stiller^  says  diarrheal  albuminuria  is  due  to  an  autotoxic  action 
of  the  renal  epithelium,  and  says  the  injurious  action  of  the  loss  of 
water  upon  the  heart  and  kidneys  is  favored  by  the  infectious  poison 
of  the  bacteria  in  cholera  as  well  as  in  acute  diarrhea. 

Uremic  ulcers  have  been  repeatedly  observed  in  the  duodenum 
and  other  parts  of  the  small  and  large  bowel  in  subjects  who  had  for  a 
long  time  been  afflicted  with  chronic  nephritis.  Other  types  of  in- 
testinal ulcers  invariably  excite  peristalsis  and  augment  the  secretions 
and  peristalsis  and  cause  diarrhea,  and  there  is  every  reason  for  be- 
lieving that  these  ulcers  act  likewise.  Considerable  difference  of 
opinion  exists  as  regards  the  etiology  of  the  lesions,  and  different 
'  Ungarische  Mediz.  Presse,  Nos.  3  and  4,  1900. 


DIABETES    MELLITUS,    DIARRHEA    IN  63 

authorities  have  attributed  them  to  (a)  irritation  by  the  carbonate 
of  ammonia;  (b)  hemorrhagic  infarc^ts  into  the  submucosa;  and  (c) 
excretion  of  irritating  toxins  into  the  hcnvel. 

SHghtly  increased  evacuations  are  unimportant  from  a  prognostic 
standpoint,  but  when  exhausting  cHarrhea  is  associated  with  nausea, 
vomiting,  and  migraine  the  patient  is  usually  very  ill,  on  the  verge 
of  serious  uremic  poisoning,  and  is  likely  to  die  unless  the  acute 
attack  subsides  rapidly.  Strange  as  it  may  seem,  frequent  profuse 
serous  evacuations  are  at  times  apparently  heljiful,  because  marked 
edema  of  the  skin  has  been  observed  to  disappear  simultaneously  with 
the  attacks,  probably  owing  to  drainage  of  the  parts  through  the  cir- 
culation and  by  way  of  the  intestine. 

Bartels  maintains  blood,  purulent  masses,  or  mucus  may  occur 
in  the  stools  in  the  absence  of  ulcers,  and  has  shown  by  autopsy 
that  where  transudation  has  taken  place  the  intestinal  mucosa  is 
edematous. 

Treatment. — Every  effort  should  be  made  to  limit  the  progress  of 
— or  heeil — lesions  within  the  kidney  or  correct  any  abnormality  which 
interferes  with  the  functionating  power  of  the  organ,  to  lessen  the 
formation  of  the  toxins  and  waste  products  which  so  profoundly  affect 
the  general  system,  and,  in  addition,  much  can  be  done  toward  mak- 
ing the  patient  comfortable  and  freeing  the  intestine  of  its  irritating 
and  poisonous  contents  by  flushing  the  colon  with  hot  normal  saline 
or  a  mildly  medicated  solution. 

No  special  effort  should  be  made,  except  in  extreme  cases,  to  con- 
trol the  diarrhea,  because  the  patient's  condition  frequently  becomes 
worse  when  the  number  of  evacuations  are  greatly  diminished,  and, 
further,  because  ordinary  antidiarrheal  remedies  fail  except  in  unde- 
sirably large  doses. 

Diabetes  Mellitus,  Diarrhea  in. — In  rare  instances  this  mani- 
festation complicates  diabetes  mellitus  as  the  result  of  a  coexistent 
enteritis,  the  diet,  or  pancreatic  disease.  In  the  first,  the  slighth- 
increased  eviicuations  are  semiliciuid,  contain  mucus,  and  continue 
more  or  less  regularly.  In  the  second,  the  patient  complains  of  dis- 
tention, central  abdominal  pains,  which  are  followed  by  a  number  of 
watery  evacuations  that  bring  immediate  relief.  While  in  the  last, 
or  pancreatic  type  of  diabetes  mellitus,  the  evacuations  contain  an 
excess  of  fat  and  have  an  offensive  odor. 

In  some  instances,  where  nausea,  vomiting,  hiccup,  and  severe 
pain  precede  the  movements,  a  serious  turn  in  the  disease  is  indi- 
cated, and  the  patient  may  at  any  time  pass  into  diabetic  coma. 

Treatment. — In  handling  this  type  of  diarrhea  much  can  be  done 
toward  relieving  the  patient  by  having  him  live  an  out-door  life,  eat 
at  regular  hours,  and  discard  food  known  to  cause  indigestion  or  irri- 
tate the  gastro-intestinal  tract. 

In  addition,  when  there  is  an  existing  enteritis  or  colitis,  bowel 
irrigation,  medication,  and  the  measures  recommended  elsewhere  for 
the  treatment  of  these  conditions  are  indicated. 


64  ORGANIC    DISEASES,    DIARRHEA    IN 

When  diabetes  mellitus  becomes  fully  developed  it  is  necessary 
to  limit  the  manufacture  of  sugar  and  amount  of  urine  by  improving 
the  hygienic  surroundings  of  the  patient,  restricting  his  diet  as  regards 
carbohydrates  and  farinaceous  food,  and  by  resorting  to  hydrother- 
apy, massage,  and  exercise  to  eliminate  sugar.  At  the  same  time 
suitable  medication  and  foods  are  prescribed  to  maintain  his  strength 
and  increase  his  power  of  resistance.  Opiates  are  peculiarly  suitable 
in  the  treatment  of  diabetic  diarrhea,  because  they  not  only  limit 
or  control  the  evacuations,  but  greatly  assist  metabolism,  bring  rest 
and  sleep,  and  have  a  pronounced  tendency  toward  limiting  polyuria 
and  the  formation  of  sugar. 

Suprarenal  Disease  (Addison's),  Diarrhea  in. — In  this  affection 
the  suprarenal  capsules  become  enlarged  or  degenerate,  the  skin  as- 
sumes a  bronze-like  hue,  the  patient  becomes  feeble  in  body  and 
mind,  and  is  troubled  with  circulatory  disturbances,  pigmented  spots, 
headache,  dizziness,  fatigue,  roaring  in  the  head,  weak  pulse,  clammy 
skin,  polyuria,  indicanuria,  and  gastro-intestinal  disturbances,  which 
are  evidenced  by  loss  of  appetite,  nausea,  and  vomiting,  pain  in  any 
or  all  of  the  abdominal  regions,  and  persistent  diarrhea. 

The  diagnosis  is  based  principally  upon  the  previously  enumerated 
symptoms,  discoloration  of  the  skin,  and  the  enlarged  glands  must  be 
differentiated  from  carcinoma  and  tuberculosis,  with  which  they  are 
frequently  associated  locally  and  when  they  involve  distant  parts. 
While  pigmentation  of  the  skin  is  rather  characteristic,  it  is  well  to 
bear  in  mind  that  cancer,  hepatic  disturbances,  tuberculosis,  and  argyra 
affect  the  integument  in  a  somewhat  similar  manner. 

The  prognosis  is  invariably  bad,  the  patient  dies  of  weakness, 
coma,  delirium,  or  convulsions  in  about  a  year  or  eighteen  months, 
but  in  some  instances,  where  the  disease  is  rapid,  death  ensues  in  six 
months,  but  in  others  he  may  live  five  or  more  years. 

Treatment. — The  treatment  of  Addison's  disease  is  usually  hope- 
less in  so  far  as  a  cure  is  concerned,  but  much  can  be  done  to  extend 
the  patient's  life  and  make  him  more  comfortable  by  supportive  and 
symptomatic  remedies.  They  consist  in  keeping  him  quiet  and  re- 
stricting his  diet  to  concentrated  and  easily  digested  foods  which 
contain  a  liberal  percentage  of  proteins.  Iron  and  arsenic  are  the 
best  representatives  of  the  tonic  medicines,  particularly  when  employed 
in  combination  with  nucleins  or  phosphorus.  Bismuth,  tannalbin, 
and  other  agents  of  the  astringent  variety  in  5-gr.  (0.30)  or  larger  doses, 
three  or  four  times  daily,  frequently  control  diarrhea  if  moderate,  but 
when  it  is  severe  opium  should  be  used  in  conjunction  with  them  or  salol 
or  beta-naphthol  when  an  antiseptic  is  indicated.  Nausea  and  vomit- 
ing are  minimized  or  relieved  by  cerium  oxalate,  champagne,  or 
albumen-water.  Extract  of  the  suprarenal  capsules  has  in  some 
cases  given  very  good  results,  but  has  not  been  tested  a  sufficient 
number  of  times  to  warrant  the  belief  that  it  will  prove  universalh' 
successful  in  this  class  of  cases. 

Genital  Diseases,  Diarrhea  in. — Of  the  bowel  disturbances,  con- 


GENITAL    DISEASES,    DIARRHEA    IN  65 

stipation  and  diarrhea,  which  frequently  accompany  abnormalities 
and  disease  of  the  sexual  organs  in  women,  the  latter  at  times  adds 
materially  to  the  patient's  discomfort.  Most  often  this  symptom 
occurs  during  the  menopause,  and  may  result  from  the  engorged  and 
highly  sensitive  state  of  the  parts  or  to  the  extremely  nervous  con- 
dition of  the  patient.  This  type  of  frequent  movements  is  encoun- 
tered most  frequently  in  hysteric  and  neurasthenic  women,  and  par- 
ticularly those  suffering  from  uterine  catarrh,  tumors,  displacements, 
or  extensive  cervical  ulceration. 

Xot  infrequently  disease  of  the  female  pelvic  organs  or  genital 
apparatus  results  in  extension  of  the  inflammatorv-  process  to  the 
sigmoid  flexure  or  rectum,  causing  proctitis  and  acceleration  of  the 
evacuations  which  contain  considerable  mucus,  or  an  abscess  forms, 
opens  into  the  bowel,  and  sets  up  an  irritative  diarrhea  accompanied 
by  tenesmus.  Abnormally  frequent  passages  often  occur  where  there 
is  a  complete  laceration  of  the  perineum,  but  here  the  trouble  is  not 
due  to  diarrhea,  but  to  incontinence  and  the  patient's  inability  to 
retain  liquid  and  semisolid  feces  until  absorption  takes  place  and 
they  become  firm.  This  is  easily  demonstrable  by  correcting  the  de- 
formity, when  the  stools  again  become  normal.  A  frequent  desire  to 
evacuate  the  bowel  may  also  accompany  vaginismus  and  the  passage 
of  the  child's  head  during  labor. 

Persistent  diarrhea,  complicated  by  colonic  distention,  colic,  and 
the  discharge  of  an  abnormal  amount  of  mucus,  has  been  obser\-ed  in 
the  presence  of  o\arian  tumors  with  axial  rotation,  the  cause  of  which 
is  not  known,  but  the  disturbance  is  probably  due  to  reflex  impulses 
originating  in  the  traumatized  ner\-es,  local  congestion,  pressure  upon — 
and  irritation  to — the  bowel  by  the  tumor  mass,  retention  within 
the  gut  of  feces  and  toxins  (from  the  same  cause),  or  rupture  of  the 
cyst  into — or  direct  involvement  of — the  bowel  by  a  disintegrating 
tumor. 

The  author  has  also  treated  severe  cases  of  diarrhea  in  women 
which  apparently  resulted  from  ner\ous  and  operative  sequelae. 

Treatment. — It  is  obvious  when  diarrhea  is  induced  by  disease  or 
displacement  of  a  part  of  the  sexual  apparatus  that  such  an  exciting 
factor  must  be  corrected  before  the  frequent  evacuations  can  be  satis- 
factorily controlled,  except  where  the  bowel  disturbance  is  the  result 
of  psychic  impulses  or  nervousness. 

When  diarrhea  is  traceable  to  ner\e  derangement,  strychnin,  arsenic, 
iron,  or  other  tonics  should  be  prescribed  along  with  a  non-irritating, 
nourishing  diet,  moderate  exercise  in  the  fresh  air  and  sunshine  to 
strengthen  the  patient;  but  the  most  important  thing  is  to  encourage 
the  suff^erer  and  take  her  out  of  unhygienic  and  dismal  surroundings 
and  better  her  environment. 

When  frequent  movements  are  induced  by  reflex  disturbance, 
pressure  upon  the  bowel  by  a  retroverted  uterus,  or  the  discharge  into 
it  of  an  abscess,  surgical  inter\-ention  is  imperative,  and  the  diarrhea 
quickly  ceases  following  removal  of  these  conditions. 


66  ORGANIC    DISEASES,    DIARRHEA    IN 

When  frequent  evacuations  dominate  the  symptom-complex,  it 
may  be  necessary  to  prescribe  opium  and  belladonna  or  other  reliable 
antidiarrheal  remedies  to  control  the  movements  until  the  disease 
causing  the  trouble  can  be  removed  by  operative  or  other  measures. 

Diarrhea  which  complicates  abnormalities  or  disease  of  the  male 
genital  organs  may  be  caused  by  luetic  or  gonorrheal  infection;  the 
discharge  into  the  rectum  of  pus  from  prostatic  abscesses,  or  urine 
through  a  rectovesical  fistula;  extension  of  inflamma.tion ;  malignant 
or  other  diseases  of  the  bladder,  prostate,  or  urethra;  vesical  or  urethral 
calculi;  blocking  of  the  rectum  by  an  enlarged  prostate,  and  reflex 
disturbances. 

The  source  of  irritation  responsible  for  diarrhea  can  usually  be 
ascertained  by  cystoscopy,  sounding  the  bladder  and  urethra  for  cal- 
culi and  strictures,  palpating  and  percussing  the  vesical  region,  inves- 
tigating the  rectum  with  the  finger  or  through  the  proctoscope,  and 
by  examining  the  urine  and  feces  to  find  out  if  they  contain  pus,  gono- 
cocci,  or  anything  which  would  assist  in  clearing  up  the  diagnosis. 

Treatment. — Diarrhea  consequent  upon  disease  of  the  male  genital 
organs  can  be  modified  by  medication,  but  a  cure  will  not  occur  until 
the  source  of  irritation  or  blocking  has  been  removed  by  operation  or 
relieved  by  treatment.  To  insure  permanent  results  in  this  class  of 
cases  rectovesical  fistulae  should  be  closed  by  plastic  surgery,  abscesses 
should  be  opened,  curetted,  and  drained,  vesical  tumors,  calculi,  and 
enlarged  prostates  should  be  removed,  urethral  strictures  and  sensi- 
tive spots  causing  reflex  disturbances  should  be  corrected,  and  topical 
applications  should  be  made  to  the  rectum,  or  it  should  be  irrigated 
with  antiseptic  and  stimulating  solutions,  when  inflamed  or  ulcerated. 

Urinary  Diarrhea. — This  type  of  diarrhea  is  most  frequently  as- 
sociated with  the  retention  and  absorption  of  urine,  but  occasionally* 
complicates  septic  and  other  disease  processes  of  the  urinary  tract. 
The  diarrheic  manifestation  may  vary  from  a  slight  acceleration  of 
the  movements  to  manifold  watery  stools  not  unlike  those  designated 
as  dysenteriform.  The  frequency  and  severity  of  the  attacks  depend 
upon  the  degree  of  toxemia,  disturbance  to  the  nervous  system,  and 
local  irritation.  When  the  first  is  very  marked  the  patient  also  com- 
plains of  nausea,  vomiting,  and  other  evidences  of  severe  gastro-intes- 
tinal  involvement.  The  author  has  more  often  observed  diarrhea  in 
connection  with  impermeable  stricture  and  purulent  cystitis  than  in 
other  ailments  of  the  urinary  apparatus,  but  in  two  instances  has 
treated  patients  suffering  from  obstructive  diarrhea  caused  by  pros- 
tatic enlargement  in  one  instance,  and  carcinomatous  degeneration 
of  the  gland  in  another. 

Raskai  has  recorded  several  cases  where  obstinate  diarrhea  was 
complicated  by  bacteruria,  with  and  without  cystitis,  some  of  which 
were  due  to  the  colon  bacillus. 

Treatment. — This  consists  in  correcting  the  local  trouble,  bowel 
irrigation,  and  the  administration  of  drugs  to  control  the  frequent 
movements  when  feasible. 


SKIN    DISEASES,    DIARRHEA    IN  67 

Skin  Diseases,  Diarrhea  in. — Diarrhea  has  been  occasionally 
observed  in  connection  with  certain  skin  diseases,  the  attacks  being 
of  short  duration  in  some  and  longer  in  others. 

In  urticaria  (which  is  marked  by  pinkish,  flat  elevations  of  the  skin 
accompanied  by  itching,  stinging,  or  pricking  sensations)  frequent 
evacuations  have  been  known  to  occur,  both  when  no  exciting  cause 
for  the  eruption  was  discoverable  and  when  it  was  caused  by  the 
eating  of  shell-fish  or  due  to  ptomain-poisoning.  In  this  class  of  cases, 
in  addition  to  the  itching  and  swollen  skin  patches  in  aggravated  cases, 
there  may  be  dyspepsia,  nausea,  vomiting,  and  colic,  accompanied 
by  frequent  offensive  diarrheic  movements.  Some  writers  attribute 
the  intestinal  manifestations  to  the  urticarial  disturbance,  but  the 
author  believes  that  the  skin  affection  is  secondary  to,  and  caused  by, 
gastro-intestinal  ailments,  particularly  auto-intoxication  (or  ptomain 
toxins),  since  urticaria  can  be  relieved  most  quickly  by  the  administra- 
tion of  hydragogue  cathartics  in  successive  doses  to  cleanse  the  bowel. 

Acrodynia  {erythema  endemiciim),  uncommon  in  this  country,  but 
frequently  observed  among  the  soldiers  and  prisoners  of  Paris  and  of 
far  eastern  countries,  is  accompanied  by  disturbance  of  the  gastro- 
intestinal tract,  and  is  usually  ushered  in  by  anorexia,  nausea,  vomit- 
ing and  diarrhea,  and  is  supposed  to  be  the  result  of  the  effect  of  an 
unknown  toxin  upon  the  central  nervous  system.  In  exceptional 
instances  the  movements  may  run  as  high  as  thirty  or  more  daily  and 
contain  considerable  blood.  It  resembles  urticaria,  in  that  there  are 
pricking  and  stinging  sensations  and  flattened  wheals  which  are  pig- 
mented. This  condition  also  resembles  arsenic-  and  ergot-poisoning 
and  pellagra.  Patients  complain  of  pain  in  the  extremities  and  some- 
times of  edema  and  muscular  spasm.  The  attack  in  favorable  cases 
runs  its  course  in  from  two  to  four  weeks,  but  convalescence  is  longer 
in  debilitated  and  aged  individuals. 

In  erythema  nodosum  the  bowel  ordinarily  is  not  disturbed,  but 
when  it  is,  the  patient  complains  of  colic  and  diarrhea. 

The  infectious  variety  of  erythema  exudativum  multiforme  may 
in  very  severe  cases  be  accompanied  by  buccal  disturbances,  ulcera- 
tion or  gangrene  of  the  pharyngeal  mucosa,  indigestion,  loss  of  appe- 
tite, vomiting,  annoying  diarrhea,  and  the  evacuation  of  a  consider- 
able amount  of  blood  both  by  way  of  the  stomach  and  the  bowel. 

Both  acute  eczema  and  pemphigus  vulgaris  when  in  an  aggravated 
form  may,  through  the  fever,  nervous  phenomena,  or  dyspeptic  mani- 
festations which  accompany  them,  induce  gastric  a-nd  intestinal  irri- 
tation and  diarrhea.  Pemphigus  acutus  is  particularK-  inclined  to 
bring  about  this  condition.  In  many  instances,  where  there  are  both 
gastro-intestinal  and  skin  manifestations,  it  is  frequently  impossible 
to  determine  which  is  the  exciting  factor. 

Pityriasis  rubra,  the  terminal  stage  of  which  is  at  times  accom- 
panied with  loss  of  appetite,  dyspepsia,  diarrhea,  and  marasmus,  and 
sclerema  neonatorum  occasionally  greath'  disturb  the  gastro-intestinal 
tract  and  cause  diarrhea. 


68  ORGANIC    DISEASES,    DIARRHEA    IN 

Treatment. — For  the  treatment  of  the  various  dermatologic  lesions 
with  which  diarrhea  is  associated  the  reader  is  referred  to  standard 
works  on  skin  diseases,  because  their  due  consideration  here  would 
be  unnecessan,'  in  a  work  of  this  character. 

Measures  employed  to  reduce  the  number  of  evacuations  in  this 
class  of  cases  must  be  changed  according  to  the  cause  exciting  the 
bowel  disturbance.  When  the  gastro-intestinal  mucosa  is  irritable 
often  much  relief  can  be  obtained  by  restricting  the  diet  to  fluid  and 
semisolid  or  non-irritating  foods  that  are  easily  digested  and  leave  a 
small,  in  preference  to  a  coarse,  bulky-  residue.  Naturally,  condi- 
ments, ice-cold  drinks,  carbonated  beverages,  and  foods  which  dis- 
agree with  the  patient  should  be  interdicted. 

Owing  to  the  annoyance  caused  by  the  frequent  evacuations,  the 
patient  desires  a  medicine  which  will  afford  him  immediate  relief, 
but  in  the  majority  of  instances  it  is  bad  practice  to  at  once  prescribe 
an  opiate  or  other  antidiarrheal  remedy  until  after  calomel  or  a  hy- 
dragogue  has  been  administered  to  correct  biliousness  and  dislodge 
fecal  accumulations;  the  toxins  which  are  formed  locally  or  reach  the 
intestines  through  the  blood  should  be  washed  out  or  neutralized,  be- 
cause, while  the  diarrhea  may  be  temporarily  checked,  it  will  recur 
until  the  intestine  has  been  thoroughly  cleansed.  Cathartics  and  laxa- 
tives internally  administered  do  not  always  accomplish  the  desired  re- 
sults, and  when  they  fail  the  colon  should  be  repeatedly  irrigated  with 
a  saline  or  one  of  the  antiseptic  or  mild  astringent  solutions  mentioned 
in  the  chapter  on  Intestinal  Irrigation  until  all  sources  of  local  irrita- 
tion are  removed.  If,  in  spite  of  this  and  the  treatment  directed 
against  the  skin  affection,  the  diarrhea  is  not  controlled,  opium  and 
belladonna  alone,  or  in  combination  with  antiseptic  or  astringent 
agents,  should  be  prescribed  in  suitable  doses  and  repeated  as  often 
as  necessary. 

Bone  Diseases,  Diarrhea  in. — The  author  has  on  several  occa- 
sions observed  children  who  suffered  from  Pott's  or  hip-joint  disease 
or  tubercular  lesions  of  the  bones  in  other  parts  who  were  also 
afiflicted  with  diarrhea,  and  who  did  not  have  ear  diseases,  degenera- 
tion of  the  intestines,  or  other  organs.  In  some  instances  the  intes- 
tinal disturbance  was  due  to  unhygienic  surroundings  and  unsuitable 
food,  but  most  often  it  was  traceable  to  catarrhal  inflammation  of 
the  bowel,  which  is  so  common  in  tubercular  and  syphilitic  subjects. 

In  these  cases  improvement  followed  correction  of  the  bone 
lesions,  a  suitable  diet,  supportive  treatment,  and  bowel  irrigation. 
KolP  has  reported  4  severe  cases  of  fetid  diarrhea  associated  with 
epiphyseal  development  of  the  bone,  in  some  of  which  cases  there 
was  hyperplastic  and  in  others  nutritional  disturbances  and  atrophic 
changes  in  the  osseous  tissue.  In  two  instances  the  bone  disease 
was  relieved  by  curing  the  intestinal  disease,  but  the  method  of 
treatment  and  result  in  the  other  cases  he  did  not  reveal. 
'  Deutsch.  Archiv.  f.  Klin.  Med.,  1910,  vol.  c,  p.  489. 


CHAPTER   IV 

AMYLOIDOSIS  OF  THE  INTESTINAL  TRACT    LARDACEOUS 
DEGENERATION),   DIARRHEA   IN 

Amyloidosis  is  not  so  common  as  formerly  because  it  is  largely 
due  to  pus  accumulations,  cachexias,  tuberculosis,  and  syphilis,  all 
of  which  conditions  are  at  present  being  treated  earlier  and  more 
effectively,  which  in  a  measure  tends  to  prevent  complications  and 
the  development  of  this  affection.  Next  to  the  kidney,  liver,  and 
spleen,  the  intestine  is  the  most  frequent  organ  to  undergo  lardaceous 
degeneration,  and  the  disease  here  is  induced  by  the  same  causes 
which  produce  it  elsewhere. 

To  show  the  comparative  frequency  of  lardaceous  degenera- 
tion of  the  bowel  to  that  of  other  organs,  Xothnagel  has  assembled 
the  statistics  of  Loomis,  Dickinson,  and  Goodhart,  which  total  468 
cases,  wherein  amyloidosis  affected  the  kidneys  in  302;  spleen,  273; 
liver,  201 ;  and  the  intestine  in  163  cases. 

Amyloid  degeneration  may  involve  all  or  any  part  of  the  digestive 
tract  from  the  esophageal  beginning  to  the  anus.  Ordinarily  the 
entire  bowel  is  involved,  but  when  it  is  not,  the  colon  is  most  often 
the  seat  of  the  disease,  and  when  the  small  intestine  is  attacked,  only 
the  ileum  is  the  part  affected. 

The  etiology  and  general  character  of  intestinal  amyloidosis  are 
the  same  as  in  other  parts,  and  it  is  not  necessary  to  do  more  than  dis- 
cuss its  gross  appearance  and  state  that  amyloidosis  may  originate 
primarily  (rarely)  in  the  bowel  or  secondarily  to  degeneration  of  the 
kidney,  liver,  or  spleen. 

Virchow  (1855)  was  the  first  authority  to  give  a  classic  anatomic 
description  of  intestinal  amyloidosis  and  call  attention  to  the  manner 
in  which  it  could  be  chemically  diagnosticated. 

In  this  affection  the  lymphoid  follicles  rarely  undergo  degeneration, 
but  in  the  later  stages  of  the  disease  the  villi  often  disappear  through 
atrophy  or  necrosis,  and  the  intestine  presents  a  waxy,  gray,  translu- 
cent, glistening  appearance,  and  the  mucosa  appears  somewhat  swol- 
len (Fig.  17).  Ulceration  nearly  always  characterizes  lardaceous 
degeneration  of  the  bowel,  and  the  ulcers  may  be  single,  but  are 
usually  multiple,  penetrating,  and  may  be  diminutive,  large  or  small, 
extensive  in  size,  particularly  when  there  is  an  active  mixed  infection. 
I'sually  they  are  not  very  large  and  present  a  punched-out  appear- 
ance, have  smooth,  raised  and  thickened  edges,  pale  base,  and  gener- 
ally show  little  tendency  to  heal.  Owing  to  the  peculiar  appearance 
given  to  the  mucosa  by  the  amyloid  changes  and  the  ulcers  which 

69 


.\MYLOIDOSIS    OF    THE    INTESTINAL    TRACT,    DIARRHEA    IN 


penetrate  it.  it  frequently  resembles  cheese  (Fig.  17^),  and  has  been 
.      _  .  _       designated    by    some   "cheesy   de- 

generation of  the  intestine." 

The  peculiar  thing  about  intes- 

^  tinal  amyloidosis  is  that  the  degen- 

^  ••      *    ^»  *  '  eraiion     attacks     principally     the 

».         «-   *  Cl  blood-vessels   (particularly  the  ar- 

terial), involving  the  capillaries  in 

k   ♦    j|K      •  *  the  mucosa,  arterial   twigs  in  the 

muscularis,    or    the    larger  vessels 
_^     ^^  of  the  intestinal  wall  alone  or  to- 

L       ^.Jflf^        "^        ^  gether.   and   shows   a   predilection 

^     •"  for    the    media   or  muscular  coat, 

though  all  the  structures  making 
up  the  intestinal  wall  may  un- 
dergo a  change.  Owing  to  the 
rigidity  and  othersvise  impaired 
condition  of  the  vascular  supply  of 
the  bowel,  anemic  spots  result, 
which  in  time  undergo  necrosis  and 
form  ulcers,  but  the  authorities 
agree  that  all  of  the  ulcerative 
areas  seen  are  not  attributable  to 
this  cause,  and  Colberg  asserts  that 
mechanic  or  chemic  irritation  must 
in  some  way  play  a  part  in  the 
etiolog\'  of  ulcerative  amyloid  de- 
generation of  the  intestine,  per- 
haps through  the  breaking  off  of 
the  fragile  villi  by  the  ingesta  in 
its  downward  passage,  or  through 
irritation  of  the  urinary  products 
in  the  feces  when  the  kidneys  are 
lardaceous. 

.  ^  The    symptoms    of     intestinal 

i^  .  '        amyloidosis  are  indefinite  in  mild, 

*  fe    *  ^^^  ^^  typical  cases  they  are  fairly 

^       *  .  characteristic,  and  diarrhea  consti- 

tutes   the    chief    manifestation    of 
kthe  disease.     The  exciting  cause  of 
•    .     *    '      '  the   frequent  movements  here  dif- 

"^  «  fers   from   that  of  other   forms  of 

^      \  *  ;,  ^  intestinal   ulceration,  in   that   they 

are  due  less  to  increased  peristalsis 
and  secretion  of  mucus  than  they 
are  to  a  lack  of  absorption,  owing 
to  the  condition  of  the  mucosa  and  impairment  to  the  local  circula- 

1  Army  Med.  Museum. 


7. — .\myloido5i5 — lardai  L 
generation  of  the  intestine. 


TREATMENT  7 1 

tion.  The  evacuations  are  frequent  and  water>^  contain  neither 
pus,  blood,  nor  mucus,  which  one  would  expect  to  encounter  in  lesions 
of  the  same  number  and  size  from  other  causes,  are  not  preceded  by 
abdominal  discomfort,  nor  is  defecation  accompanied  by  pain  or  tenes- 
mus. This  form  of  diarrhea  is  continuous,  obstinate,  exhaustive, 
and  is  largely  responsible  for  death  in  many  cases. 

The  diagnosis  of  amyloid  degeneration  of  the  bowel  is  exceedingly 
difficult,  but  can  be  arrived  at  in  a  fair  proportion  of  the  cases,  once 
diarrhea  has  developed,  by  (a)  learning  from  the  history  whether  or 
not  the  patient  has  had  tuberculosis,  bone  suppuration,  or  syphilis, 
which  might  lead  to  it;  (b)  examining  the  kidneys,  liver,  and  spleen 
to  see  if  they  are  enlarged,  rounded,  boggy,  and  lardaceous;  (c)  search- 
ing the  urine  for  amyloid  casts;  and  (d)  noting  whether  there  is  mucus, 
pus,  or  blood  in  the  stools,  the  absence  of  which  wfjuld  indicate  the 
amyloid  cause  of  the  frequent  movements. 

Again,  in  these  cases  there  is  less  disturbance  from  gas,  cramps, 
abdominal  pain,  and  defecation  causes  but  little  if  any  annoyance; 
but  when  the  kidney  is  seriously  involved  the  patient  shows  dropsical 
tendencies  of  the  legs,  the  urine  is  pale,  clear,  increased  in  quantity, 
generally  contains  a  considerable  amount  of  albumin,  and  has  a  low 
specific  gravity. 

Finally,  Virchow  has  shown  that  the  lardaceous  intestine  exhibits 
a  brownish-red  color  when  treated  with  iodin,  turns  blue  or  violet 
when  sulphuric  acid  is  used,  and  a  brilliant  rose  color  when  methyl- 
violet  is  employed. 

The  treatment  of  intestinal  amyloidosis  is  guided  largely  according 
to  its  etiology*,  being  antitubercular,  syphilitic,  or  malarial  when  one 
of  these  diseases  is  the  inciting  factor,  or  surgical  when  it  results  from 
pus  accumulation  or  diseased  bone.  When  the  process  is  general,  the 
patient  should  be  treated  symptomatically,  since  little,  if  anything, 
can  be  accomplished  toward  a  cure,  and  the  same  holds  true  in  a  large 
measure  concerning  amyloidosis  of  the  entire  intestinal  tract. 

When  the  degeneration  is  limited  to  a  part  of  the  ileum,  a  segment 
of  the  colon,  or  entire  large  bowel,  more  favorable  results  can  be  ob- 
tained in  many  instances  when  heroic  treatment  is  instituted.  Under 
these  circumstances  (the  condition  of  the  patient  permitting)  the 
diseased  portion  of  intestine  should  be  resected,  short  circuited,  or 
excluded,  according  to  the  plan  described  in  the  chapters  devoted  to 
the  Surgical  Treatment  of  Diarrhea. 

When  the  patient  refuses  or  is  too  ill  for  surgical  intervention, 
he  should  be  given  a  supportive  treatment,  including  a  nutritive, 
non-irritating  diet,  improving  his  hygienic  surroundings,  prescribing 
tonics  of  iron,  arsenic,  quinin  or  strychnin,  administering  opium  in 
combination  with  bismuth,  tannigen,  tannoform,  tannalbin,  or  ich- 
thalbin  to  diminish  the  evacuations,  and  in  frequently  washing  out 
the  colon  with  soothing,  antiseptic,  or  healing  agents  to  improve  the 
condition  of  the  mucosa  and  lessen  the  danger  from  mixed  infection. 


CHAPTER  V 

ACUTE   INFECTIOUS   AND   CONTAGIOUS   DISEASES, 
DIARRHEA   IN 

1VIE.\SLES.   SCARLET  FEVER.  V.\RICELLA.  V.\RIOLA.  VHOOPDJG -COUGH 
'PERTUSSIS  .   DIPHTHERL\,   E\TLUENZ.\,   PNEU':vIONL\,   ^L\L.\RL\ 

Diarrhea  of  Acute  Infectious  Diseases. — The  regularity  of  the 
movements  and  their  consistence  are  interfered  with  at  one  time  or 
another  in  nearly  all  general  infectious  and  contagious  diseases.  In 
some  instances  obstinate  constipation  prevails,  but  frequently  there 
is  a  diarrheal  tendency  and  the  evacuations  are  increased  from  three 
to  fifteen  or  twent\'  daily,  according  to  the  severity  of  the  case,  causing 
great  discomfort  and  weakness. 

Diarrhea  may  occur  during  the  course  of  acute  infectious  dis- 
eases in  adults,  but  is  encountered  most  often  in  infants  and  children, 
and  frequently  proves  a  serious  complication. 

It  is  conceded  that  in  this  class  of  cases  the  direct  or  indirect  cause 
of  the  gastro-intestinal  disturbance  and  diarrhea  under  varying  condi- 
tions may  be  of  nervous,  muscular,  chemical,  bacterial,  or  toxic  ori- 
gin. Sometimes  the  bowel  remains  intact,  while  in  other  instances 
the  mucosa  becomes  inflamed  or  ulcerated,  owing  to  local  infection, 
and  the  lesions  increase  the  evacuations  by  (a)  exposing  the  nerve- 
endings  to  trauma  and  irritating  discharges  which  lead  to  frequent 
and  marked  peristalsis;  (b)  increasing  the  secretion  of  mucus  and 
transudation  of  fluid  into  the  bowel;  (c)  interfering  with  absorption 
which  leaves  a  greater  amount  of  fluid  to  be  evacuated.  Acute 
infectious  diseases  (particularly  in  early  life)  exert  a  baneful  influence 
because  of  the  intestinal  catarrh  which  accompanies  them  and  their 
tendency  to  lower  the  patient's  resistance,  which  aft'ord  the  colon 
bacillus  and  other  pathogenic  bacteria  (normal  inhabitants  of  the 
bowel)  an  opportunity-  to  multiply  and  increase  their  toxic  products, 
which  in  turn  augments  the  gastro-intestinal  disturbance  by  causing 
frequent  movements,  colic,  t\mpanites,  enterospasm,  and  constitu- 
tional manifestations,  viz. :  increased  temperature,  pulse-rate,  and 
ner\-ous  symptoms. 

Again,  diarrhea  in  acute  infectious  diseases  may  without  local 
lesions  cause  frequent  movements  through  the  action  of  toxins  upon 
the  intestinal  ner\es,  brain,  or  general  ner\-ous  system.  Internists 
have  directed  attention  to  diarrhea  with  an  infectious  basis  without 
intestinal  lesions,  and  point  to  the  fact  that  in  incipient  typhoid, 
croupous  pneumonia,  erysipelas,  influenza,  measles,  etc.,  diarrhea 
often  ensues.     In  dift'erent  cases  this  can  be  accounted  for  bv  the 


DIARRHEA    OF    ACUTE    INFECTIOUS    DISEASES  73 

nervous  state  of  the  j)atient  (psychical  disturbance  incited  iiy  the  dis- 
ease), effect  of  the  toxins  upon  the  nerves,  or  irritant  action  of  the 
poison  upon  the  intestinal  mucosa.  The  author  on  various  occasions 
has  examined  the  rectum  and  sigmoid  flexure  through  the  proc- 
toscope and  sigmoidoscope  during  and  following  attacks  of  acute 
infectious  diseases  wherein  diarrhea  was  a  complication.  In  every 
instance  there  were  evidences  of  catarrh  (mucus,  pus,  or  blood,  alone 
or  admixed),  or  erosions  or  ulcers  were  found  in  numbers  sufificient 
to  account  for  the  loose  movements.  In  some  instances  the  local 
lesions  w'cre  simple  in  character,  and  had  existed  previous  to  the 
infection,  or  were  a  manifestation  of  the  disease;  while  in  others,  ex- 
amination of  the  discharge,  scrapings  from  the  ulcers,  or  an  analysis 
of  the  sto(jls  demonstrated  that  the  lesions  w^ere  specific  and  due  to 
the  infectious  disease. 

In  conjunction  with  his  colleague.  Dr.  Pisek,  a  necropsy  was  per- 
formed by  the  author  upon  an  infant  who  died  from  diphtheria  wherein 
diarrhea  was  a  serious  complication.  In  this  case  the  rectum  and 
sigmoid  flexure  were  extensively  ulcerated,  and  the  gross  and  micro- 
scopic examinations  of  the  removed  bowel  showed  that  the  lesions 
were  diphtheric.  From  his  examinations  and  experience  with  this  and 
other  acute  constitutional  infectious  diseases  the  author  believes  that 
in  the  vast  majority  of  instances  bowel  lesions  are  present  and  can  be 
found  where  diarrhea  is  pronounced,  and  that  in  this  class  of  cases 
more  attention  should  be  paid  to  bowel  irrigation  and  topical  applica- 
tions than  is  at  present  being  done  to  overcome  complicating  diarrhea. 

Cases  have  been  observed  where  involvement  of  the  bow^el  was 
pronounced,  and  others  where  the  local  manifestations  were  less 
marked,  but  had  not  gotten  well  because  the  patient  had  been  sub- 
jected to  one  acute  infectious  disease  after  another,  which  gave  the 
bowel  no  opportunity  to  become  functionally  normal.  Under  such 
circumstances  and  where  the  patient  is  left  in  a  hysteric  condition, 
responds  actively  to  excitement  or  other  emotion,  or  is  neurasthenic, 
diarrhea  may  be  continuous  or  occur  periodically  upon  excitement 
for  a  long  time  after  the  infectious  disease  causing  it  has  disappeared, 
thus  making  it  necessary  to  care  for  the  mental  and  nervous  condition 
of  the  patient  and  avoid  errors  in  diet  wdiich  would  exacerbate  the 
diarrhea.  In  this  connection  it  may  be  said  that  constipation  pre- 
vails or  the  movements  are  but  slightly  increased  when  infection  is 
mild,  and  diarrhea  is  frequent  and  serious  in  virulent  aggravated 
infectious  diseases. 

Naturally,  the  consistence  and  composition  of  the  stools  vary  in 
different  cases,  depending  upon  the  nature  of  the  infection,  its  effect 
upon  the  bowel,  and  presence  of  a  pre-existing  pathologic  condition 
of  the  intestine.  When  diarrhea  exists  as  a  complication  the  e\"acua- 
tions  are  usually  watery,  and  fungi,  protozoa,  or  specific  bacteria 
(according  to  the  nature  of  the  infection)  are  present  in  the  feces, 
but  when  there  is  a  coexisting  irritative  or  ulcerating  enterocolitis, 
mucus,  pus,  and  blood  are  also  present. 


74      ACUTE    INFECTIOUS    AND    CONTAGIOUS    DISEASES,    DIARRHEA    IN 

With  these  general  remarks  upon  the  relation  of  diarrheal  mani- 
festations to  acute  infectious  diseases,  the  writer  will  now  discuss  the 
individual  diseases. 

Measles,  Diarrhea  in.— Generally  the  bowel  is  not  greatly  dis- 
turbed in  measles,  but  occasionally  its  function  is  temporarily  im- 
paired, and  the  patient  suffers  from  diarrhea  or  constipation.  In 
rare  instances  the  stools  may  become  frequent,  annoying,  or  even 
dangerous;  in  fact,  next  to  bronchopneumonia,  this  symptom  con- 
stitutes the  most  serious  complication  in  infants  and  young  children, 
but  is  seldom  alarming  in  adults. 

The  small  or  large  intestine,  or  both,  may  be  affected,  and  ordinar- 
ily regularity  of  the  stools  is  not  greatly  interfered  with  in  the  pro- 
dromal stage  of  measles,  but  when  it  is,  the  evacuations  are  profuse, 
occur  in  quick  succession,  rapidly  exhaust  the  patient,  and  render 
the  prognosis  extremely  rare.  On  the  contrary,  when  the  loose 
movements  do  not  begin  until  after  the  eruptive  stage,  there  is  much 
less  danger  from  this  source,  even  though  the  evacuations  are  fre- 
quent and  profuse.  When  diarrhea  and  bronchopneumonia  both 
complicate  measles,  one  may  expect  a  rapid  and  fatal  termination. 
In  cases  where  accelerated  evacuations  occur  simultaneously  with 
coryza,  or  when  absent,  with  nausea  and  vomiting,  they  are  excited 
by  an  intestinal  exanthem,  and  the  presence  of  bile  in  the  feces 
indicates  that  the  trouble  in  part  is  attributable  to  biliousness.  In 
the  later  stages,  however,  the  evacuations  frequently  take  on  a 
choleriform  or  dysenteriform  character — a  most  grave  manifesta- 
tion, particularly  in  young  children. 

Usually  the  stools  are  watery,  but  may  contain  mucus,  pure  or  in 
shreds,  some  blood,  pus,  or  an  admixture  of  all.  In  one  case  the 
diarrhea  may  be  limited  to  two  or  three  movements  and  last  but  a 
day  or  two,  while  in  another  there  may  be  ten  to  twenty  movements 
daily,  and  the  trouble  may  continue  throughout  the  disease  or  re- 
main indefinitely  when  the  mucosa  has  undergone  organic  changes, 
the  nerves  become  irritable,  or  digestion  has  been  impaired.  When 
enterocolitis  is  a  complication  the  patient  suffers  considerably  from 
cramps,  tender  spots  along  the  colon,  and  voids  a  large  amount  of 
mucus,  pus,  and  blood. 

Scarlet  Fever,  Diarrhea  in.— Scarlet  fever  is  complicated  more 
frequently  by  constipation  than  diarrhea,  but  when  there  is  sepsis 
the  evacuations  become  frequent,  foul,  of  a  greenish  color,  and  con- 
tain blood,  an  indication  that  the  patient  is  or  will  become  danger- 
ously ill. 

Varicella  (Chicken-pox),  Diarrhea  in.— \Mien  diarrhea  is  a  mani- 
festation of  chicken-pox  it  is  usually  due  to  errors  in  diet  or  incidental 
disease.  This  symptom  most  often  occurs  at  the  onset,  is  dangerous 
during  this  stage,  and  usually  ceases  with  appearance  of  the  eruption. 
The  stools  are  profuse,  obnoxious,  contain  blood  (in  the  hemorrhagic 
form),  and  are  very  difficult  to  control  with  antidiarrheal  remedies 
and  colonic  irrigation. 


INFLUENZA,    DIARRHEA    IN  75 

Variola  ( Small-poxj ,  Diarrhea  in. — Frequency  of  the  move- 
ments is  often  considerably  increased  in  small-pox  patients,  but  the 
diarrhea  is  encountered  early,  continues  until  the  eruption  appears, 
when  it  ceases  and  the  patient  feels  greatly  relieved.  In  exceptional 
cases,  where  this  symptom  prevails  during  the  later  stages  of  the 
disease,  the  evacuations  are  offensive,  exhausting,  and  indicate,  in 
the  absence  or  presence  of  intestinal  hemorrhage,  an  unfavorable 
prognosis. 

Whooping-cough  (Pertussis),  Diarrhea  in. — This  is  rarely  ac- 
companied by  diarrhea  during  the  violent  coughing  stage,  but  during 
convalescence  and  later,  owing  to  lowered  resistance,  the  patient 
frequently  develops  simple  gastro-intestinal  catarrh  or  specific  colitis 
when  the  subject  is  tubercular. 

Diphtheria,  Diarrhea  in. — As  has  been  shown  b\-  the  case  pre- 
viously referred  to  (in  the  general  remarks  upon  Constitutional  In- 
fectious Diseases),  diphtheria  is  sometimes  accompanied  by  severe 
specific  or  catarrhal  intestinal  disturbances  and  diarrhea.  When  the 
former  prevails,  the  patient  is  profoundly  poisoned,  the  intestine  is 
congested,  the  mucosa  is  extensively  ulcerated,  and  considerable  sized 
sloughs  may  be  expelled.  Owing  to  these  lesions,  effects  of  toxins 
upon  the  nervous  system  and  irritation  to  the  glands  and  nerve- 
endings  at  ulcerated  spots  caused  by  trauma  of  the  feces  and  acrid 
discharges,  persistent  diarrhea  is  incited  and  the  patient  voids  in 
rapid  succession  many  offensive  evacuations  containing  a  large 
amount  of  pus,  blood,  and  mucus,  and  unless  relief  comes  promptly 
patients  soon  die  from  exhaustion  or  sepsis.  This  condition  is  avoid- 
able when  diphtheria  is  discovered  early,  antitoxin  administered,  and 
a  proper  course  of  treatment  instituted. 

In  cases  where  frequent  movements  are  due  to  the  presence  of 
an  already  existing  enterocolitis,  or  one  which  is  temporary  and  a 
part  of  the  disease,  the  evacuations  are  less  frequent  and  offensi\-e, 
contain  an  abnormal  amount  of  mucus,  but  little,  if  any,  blood  or  pus. 

Influenza,  Diarrhea  in. — Influenza  is  usually  characterized  by  an 
inflamed  condition  of  the  mucous  membranes,  and  vers'  often  the 
gastro-intestinal  tract  is  involved  sufficiently  to  cause  nausea,  vomit- 
ing, and  abdominal  discomfort  or  pain,  with  an  increased  frequency 
of  the  evacuations,  which  contain  considerable  mucus.  In  some  in- 
stances diarrhea  is  persistent,  in  which  case  the  inciting  cause  of  the 
frequent  movements  may  be  attributed  to  catarrh  of  the  bowel,  toxins 
which  find  their  way  into  it.  irritable  and  nervous  state  of  the  patient, 
or  errors  in  diet.  The  diarrhea  may  last  a  day  or  two  throughout  the 
attack,  or  continue  regularly  or  periodically  (when  the  patient  takes 
cold,  eats  indigestible  food,  or  becomes  nervous)  for  a  long  time  after 
all  signs  of  influenza  have  disappeared.  Grip  subjects  have  often 
a  greatly  lowered  resistance  and  usually  a  congested,  sensitive,  or 
eroded  intestinal  mucosa;  all  of  which  conditions  predispose  them 
to  tubercular  and  other  types  of  bowel  infection  which  they  with- 
stand badly. 


76      ACUTE    INFECTIOUS    AND    CONTAGIOUS    DISEASES,    DIARRHEA    IN 

Pneumonia,  Diarrhea  in. — Diarrhea  often  seriously  complicates 
pneumonia  in  the  earlier  stages.  The  irritable  condition  of  the  bowel 
in  some  cases  is  attributable  to  aggravation  by  the  disease  of  a  pre- 
viously existing  enterocolitis  or  to  emigration  of  the  pneumococci 
(Weichselbaum).  Evidently  the  effect  of  the  generated  toxins  upon 
the  mucosa  and  the  local  and  general  nervous  mechanism  has  con- 
siderable to  do  with  causing  and  prolonging  the  diarrhea. 

Treatment  of  Diarrhea  Consequent  Upon  Acute  Infectious  Dis- 
eases.— In  the  handling  of  this  class  of  affections  the  first  and  most 
important  thing  is  to  take  the  necessary  precautions  to  prevent 
spreading  of  the  disease  (prophylaxis)  by  isolating  the  patient  and 
carrying  out  other  measures  for  this  purpose.  According  to  the 
nature  of  the  ailment,  the  treatment  should  be  symptomatic  or  con- 
stitutional. 

In  most  instances  the  patient  should  be  kept  quietly  in  bed,  and 
the  diet  restricted  largely  to  fluids  or  semisolids  which  are  nutritious 
and  non-irritating. 

When  there  are  indications  of  biliousness  or  of  a  fecal  accumula- 
tion or  collection  of  retained  putrefying  food  remnants  in  the  colon, 
causing  frequent  movements,  calomel  in  broken  doses,  2  to  3  gr., 
followed  in  the  morning  by  a  saline  laxative,  is  indicated  before  reme- 
dies are  prescribed  to  control  the  diarrhea  or  other  manifestations. 

Ordinarily,  in  the  treatment  of  diarrhea,  fluids  are  interdicted 
or  limited,  but  in  the  handling  of  acute  infectious  diseases  where  it  is 
a  complication  water  should  be  freely  given,  except  when  it  greatly 
accelerates  frequency  of  the  movements.  This  is  necessary  because 
in  these  affections  the  secretions  are  often  partially  or  completely 
suppressed,  toxins  accumulate  and  become  concentrated,  making 
it  important  that  the  skin,  liver,  kidneys,  and  emunctories  be  stimu- 
lated to  greater  activity  by  hot  baths,  medication  (diuretics,  etc.), 
and  increasing  the  body  fluids. 

Owing  to  a  depleted  constitution,  lowered  resistance  incident  to  a 
complicating  disease,  or  undue  virulence  of  the  toxemia,  cardiac 
complications,  weak  heart,  nervous  depression,  and  prostration  become 
troublesome  manifestations.  Under  such  circumstances  much  can 
be  done  to  sustain  the  patient  during  the  crisis  by  the  administra- 
tion of  whisky,  strychnin,  digitalis,  and  nitroglycerin  by  mouth  or 
hypodermically,  but  due  care  should  be  taken  to  avoid  overstimu- 
lation. 

Fever  plays  in  some  a  slight  and  in  others  an  important  part  in  the 
infectious  diseases,  and  measures  instituted  for  its  control  must  be 
varied  to  meet  the  indications.  Slight  fever  is  controllable  by  spong- 
ing, intestinal  lavage,  and  mild  diuretics  (such  as  potassium  citrate, 
sweet  spirits  of  niter,  and  aconite),  but  when  it  does  not  respond  to 
these  measures,  good  results  are  to  be  had  from  aspirin,  acetanilid, 
phenacetin,  or  quinin,  gr.  v  (0.30),  given  as  often  as  required,  but  the 
coal-tar  preparations  are  not  desirable  because  of  their  effect  upon 
the  heart,  and  should  not  be  prescribed  in  large  doses  or  continued 


tri:atmi:nt  of  diarrhea  i.\  acute  infectious  diseases      77 

for  a  lengthy  period.  When  the  temperature  is  regular  and  high, 
hydrotherap\-  (sponging,  cold  packs,  baths,  and  bowel  irrigation) 
should  take  precedence  over  drugs,  because  it  is  effective  and  is  fol- 
lowed by  a  beneficent  reaction  upon  the  circulation,  which  strengthens 
and  soothes  the  patient. 

In  some  of  these  infectious  diseases  general  or  local  sepsis  is  a 
serious  complication,  and  it  is  necessary  to  keep  the  emunctories 
active,  increase  the  fluids  of  the  body,  support  the  patient  with 
nourishing  food  and  stimulants,  administer  constitutional  remedies 
(chlorid  of  mercury,  creosote,  etc.)  and  local  antiseptics  (salol,  beta- 
naphthol,  salicylate  of  bismuth,  etc.)  in  large  and  frequent  doses,  and 
flush  the  colon  two  or  three  times  daily  with  a  normal  saline  or  ich- 
thyol,  2  per  cent.;  balsam  of  Peru,  2  per  cent.;  boric  acid,  3  per  cent.; 
potassium  permanganate,  i  per  cent,  solution. 

Controlling  diarrhea  complicating  acute  infectious  diseases  in 
the  main  consists  in  treating  these  affections  in  the  usual  way,  and 
in  treating  the  diarrhea  symptomatically. 

When  the  mo\-ements  are  influenced  by  emotions,  precautions 
should  be  taken  to  prevent  the  patient  from  being  frightened  over 
his  condition  or  excited  in  other  ways,  and  when  he  is  depressed, 
strychnin,  arsenic,  and  warm  baths  should  be  prescribed  to  quiet 
the  nerves  and  court  sleep. 

W^hen  the  bowel  is  disturbed  by  local  infection  the  treatment 
depends  upon  the  nature  and  extent  of  the  lesions. 

Often  there  is  simply  a  catarrhal  inflammation  of  the  mucosa, 
or  it  may  be  irritated  by  ulcers,  bacteria  or  their  toxins,  under  which 
circumstances  frequent  and  copious  colonic  irrigations  with  a  normal 
warm  saline,  Carlsbad  salt,  oij  to  Oij  (60.0-1000.0),  or  a  weak  medi- 
cated solution  such  as  boric  acid,  2  per  cent.;  permanganate  of  potas- 
sium, I  per  cent.;  balsam  of  Peru,  ichthyol.  i  per  cent.;  tannic  acid. 
0.5  per  cent.;  or  salicylate  of  soda,  i  per  cent.,  will  prove  effecti\e 
in  controlling  diarrhea  through  their  soothing  and  stimulating  action 
upon  the  bowel,  but  when  there  are  numerous  erosions  or  ulcers  of 
considerable  size  the  strength  of  the  solution  should  be  doubled  or 
tripled.  Large  ulcers  located  in  the  sigmoid  flexure  and  rectum,  not 
otherwise  curable,  can  usually  be  made  to  promptly  heal  by  topical 
applications  or  cauterization  made  through  the  proctoscope. 

Owing  to  the  fact  that  frequent  movements  in  this  class  of  cases 
are  attributable  largely  to  nervous  influence  or  lesions  within  the 
gut,  astringent  antidiarrheal  remedies  are  contra-indicated  in  most 
instances,  frequently  prove  ineffective,  and  induce  considerable 
irritation  because  they  disturb  digestion  and  fail  to  relieve  the  diar- 
rhea. 

Morphin  or,  preferably,  opium,  gr.  ^  (0.015),  and  the  extract  of 
belladonna,  gr.  |  (0.008),  administered  three  or  four  times  daily  as 
long  as  necessar>%  are  the  remedies  par  excellence,  because  they  limit 
or  arrest  the  evacuations,  relieve  pain,  and  induce  sleep.  When 
cramps  are  a  complication  and  an  opiate  is  undesirable,  much  relief 


78      ACUTE    INFFXTIOUS    AND    CONTAGIOUS    DISEASES,    DIARRHEA    IN 

is  to  be  had  from  belladonna,  gr.  j  (0.015),  and  hot  abdominal  fomen- 
tations, which  allay  pain  and  muscular  irritability. 

Owing  to  the  coryza  and  other  evidences  of  a  catarrhal  inflam- 
mation of  the  air-passages  in  measles,  influenza,  and  other  acute  con- 
stitutional infectious  diseases,  precautions  should  be  taken  to  pro- 
tect the  patient  from  drafts  and  breathing  cold  air  to  avoid  severe 
ear  and  lung  complications.  In  addition,  in  scarlet  fever  and  diph- 
theria it  is  necessary  to  frequently  spray  and  cleanse  the  nose  and 
throat  with  mild  antiseptic  solutions,  because  during  the  acute  stages 
these  parts  are  apt  to  become  infected  and  the  patient  becomes  septic, 
particularly  in  diphtheria  cases  where  antitoxin  is  not  administered 
early.  When  catarrhal  pneumonia  or  bronchopneumonia  complicate 
infectious  diseases  the  patient  should  be  protected  from  exposure  and 
the  inhalation  of  chilled  air,  and  a  supporting  treatment,  including 
nutritive  fluid  and  semisolid  foods,  tonics,  stimulants,  and  medicines 
which  will  relieve  the  cough,  diarrhea,  and  other  distressing  symp- 
toms, should  be  prescribed. 

Malaria,  Diarrhea  in. — Diarrhea  of  malaria  requires  the  same  treat- 
ment as  loose  movements  from  the  other  infectious  diseases,  with  the 
exception  that  quinin  should  be  prescribed  in  liberal  doses  as  often  and 
as  long  as  is  necessary  to  destroy  the  malarial  parasite. 

Fairly  good  results  have  recently  been  reported  from  the  use  of 
antistreptococcic  serum  in  the  treatment  of  scarlet  fever  and  inop- 
erable cases  of  septicemia,  and  this  would  seem  to  justify  the  employ- 
ment of  this  agent  in  the  treatment  of  exhausting  diarrheas  originat- 
ing from  those  and  other  septic  sources. 

Nearly  all  subjects  of  acute  constitutional  infectious  diseases  are 
left  in  a  weakened  condition,  and  have  a  lowered  resistance  and  a 
tendency  toward  gastro-intestinal  catarrh.  Consequently,  it  is  ad- 
visable, as  soon  as  possible,  to  change  their  surroundings  and  place 
them  in  the  country,  where  they  can  get  plenty  of  suitable  exercise, 
nourishing  food,  and  fresh  air  free  from  moisture. 

From  what  has  been  said  it  is  easy  to  understand  why  the  treat- 
ment of  diarrhea  accompanying  constitutional  infectious  diseases 
should  be  modified  to  suit  the  individual  case. 


CHAPTER  VI 

ACUTE  INFECTIOUS  AND  CONTAGIOUS  DISEASES, 
DIARRHEA   IN   {Concluded) 

TYPHOID,    RELAPSINCx,    AND     YELLOW    FEVERS,    CHOLERA,    WINTER 
CHOLERA,   CHOLERIFORM  DIARRHEAS,   SEPSIS,   ERYSIPELAS 

Typhoid  (Enteric)  Fever. — Diarrhea  may  be  encountered  in  an\ 
and  all  stages  of  typhoid  fever,  but  usually  follows  constipation  near 
the  end  of  the  second  week  or  about  the  time  decisive  lesions  are 
forming  within  the  small  bowel.  No  doubt  the  increased  frequency 
of  the  evacuations  are  partially  due  to  irritation,  but  they  cannot 
be  attributed  solely  to  the  swollen  plaques  or  ulcers  (Figs.  18-21),^  be- 
cause many  autopsies  ha\'e  been  performed  where  such  lesions  were 
both  numerous  and  large  and  diarrhea  was  conspicuously  absent. 
The  diarrhea  in  these  cases  is  partially  due  to  local  irritant  effects 
of  toxins  generated  within  the  intestine,  and  also  to  the  general  toxic 
condition  of  the  patient,  since  it  is  known  that  nearly  all  septicemias 
induce  frequency  of  the  movements  at  one  stage  or  another.  It  is  also 
quite  probable  that  the  bile  which  would  not  unduly  stimulate  normal 
mucosa  does  irritate  the  inflamed  gut  here  and  exaggerates  peristalsis. 

In  enteric  fever  the  movements  may  vary  from  two  or  three  to  a 
dozen  or  more  daily,  according  to  the  severity  of  the  case;  the  stools 
are  yellow  and  mushy  at  first  and  later  thinner,  resembling  in  color 
and  consistency  puree  of  peas  (due  to  bile-pigment),  alkaline  in  reac- 
tion, having  a  characteristically  disagreeable  odor,  and,  when  left 
to  stand,  the  solid  matter  settles.  During  the  critical  stage  the  evac- 
uations may  contain  sloughing  tissue  particles  and  blood  in  small 
amounts  when  coming  from  capillaries,  and  in  considerable  amounts 
when  from  larger  vessels.  In  other  respects  the  macroscopic  and  mi- 
croscopic appearance  of  the  stool  resembles  that  of  cararrhal  or  infec- 
tious enterocolitis,  ulcerati\-c  infection  of  the  bowel,  and  general  sepsis. 

Yellow  Fever,  Diarrhea  in. — This  is  an  acute  infectious  disease 
(endemic  and  epidemic)  which  formerly  destroyed  many  lives  in  the 
Southern  States,  Cuba,  etc.,  but  which  has  been  almost  eradicated  by 
improved  sanitation  and  isolating  patients  having  the  fever. 

The  disease  is  characterized  by  a  jaundiced  skin,  anemic  liver, 
friable  pancreas,  nephritis,  dark  blood,  <^landitlar  enlarfj^ement,  and  aciile 
catarrh  of  the  oastro-intestinal  mucosa  (Fig.  22)  complicated  by  minute 
hemorrhages. 

Symptoms. — Incubation  (two  lo  five  days),  anorexia,  headache,  etc. 
First  stage,  chill,  high  fever,  headache,  aching  in  limbs,  delirium,  fast 

'  .Army  Med.  Museum. 

79 


8o      ACUTE    INFECTIOUS    AND    CONTAGIOUS    DISEASES,    DIARRHEA    IN 

pulse,  swollen  gums,  burning  in  stomach,  nausea,  and  black  vomitus. 
Then  weakness,  jaundice,  collapse,  hemorrhages  (gastric),  fast  pulse, 
black  vomitus,  dry  tongue,  suppression  of  or  deficient  urine  (albu- 
min), uremic  convulsions  or  coma,  and  in  fatal  cases  terminates  in 
one  week. 


Fig.  18.  Fig.  19.                                        Fig.  20. 

Fig.  18.— Typhoid   fever.  Fig.  19.— Tjiihoid  fever.           Fig.  20.— Tyjihoid  fever. 

Appearance  of  mucosa,  first  Appearance  of  mucosa,  sec-  .Vi^pearance  of  mucosa,  third 

week.  ond  week.  week. 

Diagnosis. — By  symptoms,  exclusion,  and  Widal's  reaction. 

Prognosis. — The  death-rate  may  vary  from  i  per  cent,  in  light  to 
10  per  cent,  in  mild  and  30  to  50  per  cent,  in  severe  forms  of  the 
disease. 


CnOLHRA,    DIARRHEA    IX 


8i 


Treatment  consists  in  prophylaxis,  quarantining,  prevention  against 
and  destruction  of  the  Stegomyia  fasciata,  having  the  patient  rest  in 
bed  or  remain  upon  a  fluid  or  Hght  diet,  stimulating  the  emunctories, 
applying  ice  to  the  stomach,  and  ad- 
ministering sodium  bicarl)onate,  gr.  x 
to  XX  (0.65-1.30).  in  Apollinaris  water 
to  diminish  aciditv  of   the  secretions. 


Fig.  21. — Tj'phoid  fever.  Section  of 
transverse  colon  with  enlarged  glands 
ulcerated  at  their  apices. 


Fig.  22. — Yellow  fever  of  the 
small  intestine,  showing  capillary 
hemorrhages. 


Relapsing  Fever  fFebris  Recurrens),  Diarrhea  in. — This  affection 
is  caused  b\'  spirochetes,  characterized  by  attacks  of  fever  which  last 
for  about  a  week,  and  then  subside  to  again  recur  in  about  the  same 
time. 

Relapsing  fever  is  sometimes  complicated  by  gastric  disturbances, 
but  diarrhea  is  a  rare  complication  of  the  affection. 

The  treatment  for  it  consists  mainly  in  impro\ing  the  hygienic 
condition  of  the  patient,  having  him  remain  quiet  while  his  tem- 
perature is  high,  regulating  the  diet,  and  giving  an  opiate  when  pain 
in  the  limbs  cannot  be  otherwise  relieved. 

Cholera,  Diarrhea  in. — Epidemic  Asiatic  cholera  is  greatly  dreaded, 
because  once  it  gets  a  hold  it  spreads  rapidly  and  in  a  large  proportion 
of  the  cases  ends  fatally.  Fortunately,  ravages  from  it  are  not 
nearly  so  disheartening  as  formerly,  because  national  and  local  boards 
of  health  ha\e  learned  how  to  arrest  or  provide  against  it.  Recently 
it  made  considerable  progress  in  Russia,  southern  Italy,  and  the  Bal- 
kan States,  but,  in  so  far  as  out  possessions  are  concerned,  it  has  been 
confined  to  the  Philippines,  except  in  1873  and  1902,  when  cholera 
obtained  a  strong  footing  in  the  United  States. 

The  cause  of  this  acute  infectious  disease  is  the  comma  bacillus 
of  Koch  or  the   Vibrio  cholerce  Asiaticce.     This  organism  deri\-es  its 

6 


i2      ACUTE    INFECTIOUS    AND    CONTAGIOUS    DISEASES,    DIARRHEA    IN 


name  from  its  resemblance  to  a  comma  (,),  looks  somewhat  like 
bacilli  of  chicken  and  pigeon  cholera,  is  thicker  and  shorter  than  the 
tubercle  bacillus,  and  is  always  detectable  in  the  discharge  from 
persons  infected,  frequenth-  with  the  colon  bacillus,  which  aggra- 
vates the  condition. 

Occasionally  there  is  a  short  prodrome  of  ordinan,'*  diarrhea  in 
Asiatic  cholera,  but  in  the  vast  majority  of  instances  the  disease  is  of 
a  sudden  onset,  severe  from  the  start,  and  terminates  quickly  and 
fatally  in  a  goodly  percentage  of  cases. 

In  severe  cases  in  the  beginning  the  patient  complains  of  nausea 
and  abdominal  discomfort,  and  a  little  later  of  active  peristalsis,  with 

tenderness  over  the  small  intestine,  which  is 
soon  followed  by  diarrhea  and  softened 
stools  containing  fecal  matter.  Shortly, 
however,  the  evacuations  become  character- 
istically frequent,  profuse,  odorless,  colorless, 
and  painless,  resemble  whey  or  rice-water, 
are  neutral  or  alkaline  in  reaction,  contain 
no  fecal  matter  (i  to  2  per  cent,  solids), 
perhaps  blood,  and  the  patient  vomits  food 
and  transudated  fluid,  sutt'ers  from  dizziness, 
cramps,  complete  loss  of  appetite,  thirst, 
dr\"ness  of  the  tongue,  mouth,  and  throat, 
sensations  of  heat  and  pressure  from  the 
fluid  within  the  abdomen,  gradually  in- 
creasing weakened  heart  action,  evidences 
of  collapse,  coldness,  impaired  circulation, 
li\-id  skin,  subnormal  surface,  muscular  con- 
traction in  the  extremities  and  elevated  rec- 
tal temperature,  pinched  and  exhausted 
facial  expression,  ditticult  respiration,  partial 
suppression  of  urine,  indiff^erence  to  his  sur- 
roundings, and.  in  fatal  cases,  rapidly  suc- 
cumbs to  general  prostration. 
When  he  sur\-ives  the  above  manifestations,  gradual  improve- 
ment takes  place,  nausea  becomes  less  marked,  the  appetite  returns, 
the  movements  are  less  frequent,  and  the  feces  gradually  resume  their 
normal  solidity,  except  where  the  bowel  continues  irritable  or  there 
are  lesions  which  lead  to  periodical  attacks  of  diarrhea. 

As  would  be  expected  in  a  violent  intestinal  disturbance  of  this 
character,  the  mucosa  is  acutely  inflamed,  swollen,  edematous,  and 
irritable.  The  follicles  are  enlarged  (Fig.  2^,^)  and,  in  the  small  in- 
testine occasionally  strings  of  mucus  are  found  adherent  to  the  mucous 
membrane,  and  the  bowel  is  filled  with  the  transudated  rice-water 
discharge,  especially  in  cases  where  there  is  a  paretic  tendency. 
Exceptionally,  fairly  well-developed  ulcers  are  observed. 

The  diagnosis  of  cholera  is  usually  apparent  when  it  is  epidemic 
'  Armv  Med.  Museum. 


iQUCOsa  in  Asiatic  cholera. 


CHOLFRA,    DIARRHEA    IN  83 

in  the  \icinil\-,  buL  wluu  ilurc  is  thjubt  as  to  whether  the  patient 
suffers  from  Asiatic  cholera,  ch(jlera  morbus,  or  choleriform  diarrhea, 
the  diagnosis  can  be  ciuickly  cleared  up  by  examining  the  stools  and 
finding  the  comma  bacillus  (verified  by  gelatin  or  agar  plate  cultures), 
and  by  ascertaining  if  the  patient  has  taken  arsenic,  mercury,  or 
other  drug  which  would  cause  evacuations  simulating  those  of  cholera. 

The  prognosis  of  Asiatic  cholera  is  grave,  because  a  large  per- 
centage of  the  cases  die  within  two  days  or  later,  during  the  so-called 
typhoid  stage;  occasionally,  however,  the  infection  is  not  virulent 
and  the  patient  recovers  in  a  comparatively  short  time. 

Treatment. — The  prophylactic  measures  consist  in  isolating  the 
patient  and  disinfecting  the  stools  and  everything  that  has  been  in 
contact  with  him.  Treatment  of  the  disease  proper  consists  chiefly  in 
withdrawing  foods  likely  to  irritate  the  stomach  or  intestine,  admin- 
istering calomel  in  large  or  broken  doses  when  the  patient  is  bilious, 
in  prescribing  morphin,  gr.  j  (0.015),  or  powdered  opium,  gr.  ^  (0.03), 
to  relieve  intestinal  pain  and  cramps;  water  in  abundance,  to  take  the 
place  of  that  lost  by  the  constant  transudation  and  rapid  evacuations. 

During  the  comparatively  recent  epidemic  in  the  Philippines 
benefit  was  derived  from  a  normal  salt  solution  (enteroclysis  and 
hypodermoclysis).  The  more  of  the  solution  used,  the  better,  and  in 
order  to  get  the  quickest  and  best  results  the  patient  should  be  in- 
verted, the  sigmoidoscope  introduced,  and  from  a  half  to  a  gallon  of 
the  hot  saline  should  be  poured  directly  into  the  bowel,  which  is  easily 
accomplished  wdthin  five  or  ten  minutes.  From  numerous  experiments 
made  the  author  is  certain  that  a  portion  of  the  solution  thus  intro- 
duced reaches  the  small  intestine. 

This  treatment  is  soothing  owing  to  the  heat,  strengthening  be- 
cause the  fluid  enters  the  circulation,  and  generally  beneficial  because 
it  limits  the  multiplication  of  bacteria  and  washes  out  the  toxins. 
The  irrigations  should  be  repeated  as  often  as  the  patient  will  permit. 

Kausch  highly  recommends  the  subcutaneous  or,  preferably,  in- 
travenous infusion  of  grape-sugar  in  the  treatment  of  cholera.  Begin- 
ning with  1.000  c.c.  of  a  5  per  cent,  solution,  he  gradually  increases 
the  concentration  and  quantity  of  fluifl  with  each  injection,  which  is 
made  two  or  more  times  daily.  Practically  all  the  sugar  is  taken  up 
by  the  organism  and  helps  to  sustain  the  system. 

Gastric  lavage,  in  combination  wdth  the  treatment,  is  of  great 
value  in  these  cases.  The  author  has  never  treated  a  case  of  Asiatic 
cholera,  but  from  his  experience  in  the  handling  of  cholera  nostras 
and  choleriform  diarrheas,  dysentery,  etc.,  he  believes  that  many 
patients  treated  by  the  older  plan  could  be  saved  if,  as  soon  as  the 
nature  of  the  disease  was  discovered,  his  cecostomy  (see  Figs.  142,  145), 
which  provides  a  quick  and  easy  method  of  irrigating  both  the  small 
and  large  intestme,  was  performed,  because  with  the  aid  of  this  pro- 
cedure complete  intestinal  irrigation  of  the  entire  intestinal  tract 
could  be  carried  out  as  often  as  indicated  w^ith  water  or  saline  or 
medicated  solutions. 


84      ACUTE    INFECTIOUS    AND    CONTAGIOUS    DISEASES,    DIARRHEA    IN 

It  has  been  demonstrated  that  cholera  germs  may  be  swallowed 
and  do  little  or  no  damage  in  one  case,  while  in  another  death  shortly 
ensues,  accordingly  as  they  rapidly  multiply  or  generate  toxins.  If 
this  is  so,  then  the  line  of  treatment  suggested  by  the  author  ought 
to  greatly  minimize  the  attack  or  affect  a  cure,  because  the  increase 
of  bacteria  and  their  toxins  could  be  prevented  by  frequent  gastro- 
intestinal lavage. 

Choleriform  and  Cholerine  Diarrhea. — The  expressions  choleri- 
jorm  and  cholerine  ha\"e  been  employed  by  some  authorities  to  indi- 
cate exceedingly  mild  Asiatic  cholera,  but  they  are  confusing  because 
they  have  also  been  used  for  other  purposes.  Consequently,  from 
the  author's  view-point,  all  cases  of  diarrhea  incited  by  the  comma 
bacillus  should  be  designated  as  cholera,  and  the  captions  choleriform 
and  cholerine  should  be  reserved  to  indicate  the  profuse  watery  diar- 
rhea in  other  conditions  where  the  Vibrio  cholercB  AsiaticcB  is  absent. 
These  terms  are  also  frequently  confused  with  cholera  morbus  of 
adults  and  cholera  infantum  of  infants  and  children,  conditions  hav- 
ing practically  the  same  etiolog\-  and  pathology-,  but  which  prevail 
during  warm  or  hot  periods,  and  because  of  this  should  be  considered 
as  seasonal  ailments. 

Choleriform  and  cholerine  diarrhea  have  no  entity,  and  on  account 
of  this  these  terms  are  not  employed  by  the  author  to  indicate  a  par- 
ticular type  of  disease,  but  to  designate  the  intensity  of  the  diarrheal 
condition  in  any  ailment  where  the  stools  are  frequent,  thin,  and 
composed  of  transudated  fluid  and  otherwise  resemble  the  evacuations 
in  Asiatic  cholera. 

Cholera  Nostras  (Sporadic  Cholera),  Diarrhea  in. — Cholera  nos- 
tras may  be  encountered  at  any  time  of  the  year  and  at  any  age,  but 
it  unquestionably  occurs  very  much  more  frequently  in  the  warm 
months  (June  to  September)  than  at  other  times. 

Cholera  nostras  is  generally  believed  to  be  of  specific  origin,  and 
the  colon  bacillus  is  thought  to  play  a  prominent  part  in  its  produc- 
tion, and  it  may  be  that  streptococci  work  in  harmony  with  this 
organism,  because  virulent  specimens  of  both  have  frequently  been 
simultaneously  discovered,  but  suflicient  proof  is  not  yet  forthcoming 
to  convince  one  that  they  are  the  only  causes  of  this  condition.  In 
fact,  the  spirillum  of  Finkler  and  Prior  is  often  discovered  in  e\'acua- 
tions  coming  from  persons  afflicted  with  cholera  nostras,  and  some 
authorities  considered  this  agent  the  specific  factor  in  the  disease. 
Again,  the  bacillus  of  Shiga  and  the  Flexner-Harris  and  like  organ- 
isms have  also  been  detected,  and  some  believe  that  they  are  the 
principal  causes  of  the  trouble.  Ordinarily,  when  either  of  the  last- 
named  micro-organisms  are  present  and  the  disease  is  fully  developed, 
definite  lesions  of  the  mucosa  are  discoverable  through  the  sigmoido- 
scope, and  the  discharges  contain  more  or  less  blood  and  some  pus, 
while  under  other  circumstances  these  manifestations  are  entirely 
absent  or  much  less  marked.  Because  of  this,  it  has  been  the  custom 
of  the  author  to  classif\"  diarrheas,  where  the  stools  contained  the  Shiga 


CHOLERA    NOSTRAS    (SPORADIC    CHOLERa),    DIARRHEA    IN  85 

or  Flexner-Harris  bacillus,  as  dysenteric,  but  in  the  absence  of  blood, 
where  other  organisms  are  present,  as  cholera  nostras  (morbus),  this 
arrangement  is  not  always  satisfactory  because  of  varying  severity 
of  the  attacks  and  complications  which  arise. 

In  support  of  the  theory  that  cholera  nostras  is  not  of  bacterial 
origin,  some  authorities  site  the  well-known  fact  that  an  attack  may 
be  brought  on  by  sudden  overheating  or  chilling,  the  drinking  of  ice- 
water  and  other  cold  beverages,  and  the  eating  of  certain  shell- 
fish, ingestion  of  poisons,  irritating  foods  and  fruits,  and  impure 
water. 

The  symptoms  are  of  sudden  onset,  and  begin  with  nausea,  which  is 
followed  shortly  by  vomiting,  abdominal  pain  and  tenesmus,  and  a 
violent  or  exhausting  diarrhea.  At  first  the  stomach  expels  food,  but 
later  nothing  but  mucus  and  bile,  and  the  evacuations,  which  in 
the  beginning  are  composed  of  fecal  matter,  later  rapidly  follow 
each  other  and  become  soft,  watery,  and  greatly  resemble  the  rice- 
water  discharges  of  Asiatic  cholera.  Within  a  few  hours  the  patient 
shows  the  rapid  progress  of  the  disease  in  his  thirst,  pinched  expres- 
sion, clammy  perspiration,  cold  skin,  small  weak  pulse,  impoverished 
circulation,  indications  of  collapse,  and  often  unconsciousness. 

Exceptionally,  persons  afflicted  with  cholera  nostras  die,  but,  as 
a  rule,  the  distressing  symptoms  gradually  abate,  partially  or  com- 
pletely, unless  sequeke  are  left,  in  which  case  diarrhea  may  continue 
upon  slight  provocation. 

In  making  the  diagnosis  it  is  necessary  to  differentiate  between 
cholera  morbus,  amebic  and  bacillary  dysentery,  ptomain  food  poi- 
soning, and  Asiatic  cholera  (during  epidemics),  which  when  present 
are  manifested  by  amebse  or  bacilli  of  Koch  (comma  bacillus),  Shiga, 
or  Flexner-Harris  in  the  evacuations.  When  cultures  show  the 
colon  bacilli  alone  or  in  conjuncture  with  streptococci  to  be  of  a 
virulent  type,  one  is  justified  in  attributing  the  cholera  nostras  to  this 
organism,  but  when  they  are  lacking,  and  there  is  evidence  that  the 
patient  has  taken  considerable  arsenic,  mercury,  been  indiscreet  in  his 
diet  or  has  eaten  unhealthy  food,  the  cause  can  be  ascribed  to  mechanic 
irritation,  putrefaction,  or  ptomain-poisoning. 

The  treatment  oi  cholera  nostras  must  be  varied  to  suit  the  individ- 
ual case  at  the  time  when  seen,  because  it  may  be  necessary  to  sub- 
stitute one  therapeutic  measure  for  another,  according  as  the  symp- 
toms vary  from  time  to  time,  and  the  treatment  effective  in  an  adult 
is  not  always  suitable  for  infants  and  children. 

Under  all  circumstances  it  is  wise  to  temporarily  restrict  the 
diet  to  fluids  consisting  of  predigested  milk,  soups,  nourishing  broths, 
strained  gruels,  and  interdict  cold  drinks  and  carbonated  beverages 
until  the  acute  crisis  is  over,  when  raw  or  soft-boiled  eggs,  beef-juice 
extract  or  chopped  beef,  custards,  milk  pudding,  milk  toast,  boiled 
rice,  and  similar  articles  of  diet  may  be  allowed.  Later,  as  the  patient 
gains  strength  and  the  movements  have  become  nearly  normal  in 
frequency-  and  consistence,  more  solid  foods  agrccal)le  to  the  patient 


86      ACUTE    INFECTIOUS    AND    CONTAGIOUS    DISEASES,    DIARRHEA    IX 

can  be  gradually  permitted.  These  patients  suffer  greatly  from  intes- 
tinal toxemia  and  loss  of  the  body  fluids.  Consequently,  it  is  advis- 
able to  immediately  prescribe  copious  bowel  flushings  until  the 
patient's  condition  is  markedly  improved,  when  the  injections  are 
given  less  often  until  inflammation  of  the  mucosa  subsides.  A  normal 
saline  or  weak  solutions  of  magnesium  sulphate,  boric  acid,  ichthyol, 
tannic  acid,  or  permanganate  of  potash  (i  to  2  per  cent.)  maybe  em- 
ployed to  cleanse  the  bowel,  but  the  salt  preparation  is  preferable 
because  it  accomplishes  this  purpose  and  is  absorbed,  partly  replacing 
the  fluid  loss  by  the  transudation. 

Gastric  lavage  frequently  affords  the  patient  much  relief,  par- 
ticularly in  cases  where  chemic  poisons  or  ptomains  are  the  exciting 
cause,  but  when  this  simple  measure  does  not  arrest  nausea  and 
vomiting,  a  mustard  plaster  applied  to  the  stomach  often  brings  the 
desired  relief.  The  author  has  succeeded  best  in  relieving  gastric 
irritability  and  abdominal  cramps  by  having  the  patient  drink  abun- 
dantly of  hot  water,  use  continuous  hot  moist  abdominal  applica- 
tions, and  by  the  administration  of  a  pill  or  powder  containing  opium, 
gr.  I  (0.015),  srid  belladonna,  gr.  |  (0.008).  every  two  or  three  hours 
until  the  pain  is  relieved,  except  in  urgent  cases,  where  morphin  h\- 
podermically  was  administered. 

In  cases  where  the  patient  is  bilious,  has  taken  poison,  there  is 
fecal  impaction  or  putrefying  food  remnants  in  the  bowel,  the  above 
quieting  medicines  should  be  preceded  by  calomel,  castor  oil.  or  a 
saline  laxative  to  stimulate  the  liver  and  free  the  bowel  of  its  irritat- 
ing contents. 

Bland  and  antiseptic  remedies,  such  as  magnesia,  charcoal,  bis- 
muth subnitrate.  subcarbonate  or  salicylate,  salol  or  beta-naphthol. 
gr.  V  (0.30).  three  times  a  day.  alone  or  in  combination,  do  much 
toward  restoring  the  bowel  to  its  normal  condition  after  acute  mani- 
festations have  subsided. 

Future  attacks  are  provided  against  by  watching  the  patient's 
diet,  preventing  him  from  becoming  overheated,  taking  violent  ex- 
ercise, exposing  himself  to  inclement  weather,  and  improving  his 
general  condition. 

Winter  Cholera. — In  recent  years  there  have  been  a  number  of 
epidemics  of  intestinal  flux,  or  choleriform  diarrhea,  which  have  broken 
out  during  cold  weather.  The  manifestations  of  the  condition  are 
variable,  and  may  resemble  those  of  cholera,  dysenteric  colitis,  t\'- 
phoid  fever,  or  milder  intestinal  affections.  The  term  "winter  cholera" 
was  first  employed  in  1881  (Michigan  Board  of  Health),  but  the  affec- 
tion did  not  attract  attention  until  1898,  when  sporadic  cholera 
(winter  diarrhea)  broke  out  at  Escanaba,  Mich.,  and  caused  a  num- 
ber of  deaths.  Epidemics  of  winter  cholera  occurred  in  Michigan 
City  in  1901-02.  and  the  disease  has  been  encountered  in  other  sec- 
tions of  the  Middle  West  with  more  or  less  frequency  since  then. 

The  etiology  of  winter  cholera  is  not  understood.  Some  investi- 
gators attribute  it  to  cold  weather,  since  it  is  met  with  onK"  during  the 


WINTER    CHOLERA  87 

winter,  but  others  maintain  that  such  epidemics  are  traceable  to 
polluted  water,  which  is  probably  correct,  since  the  causative  agents 
of  typhoid  fever  and  bacillary  colitis  have  been  encountered  in  the 
stools  of  patients  afflicted  with  winter  cholera,  as  ha\'e  also  the  colon 
and  Bacillus  enteritidis  sporogenes,  and  other  pathogenic  organ- 
isms. No  doubt  in  some  instances  there  is  a  mixed  infection.  This 
type  of  diarrhea  has  frequently  been  associated  with  influenza,  which 
some  regard  as  the  cause  of  the  loose  mov^ements,  but  in  the  Escanaba 
epidemics  (1907-08)  Pfeiffer's  bacillus  was  not  demonstrable,  and 
there  was  no  reason  for  attributing  the  diarrhea  to  this  cause. 

Winter  cholera  has  an  uncertain  pathology,  and  in  different  cases 
the  changes  in  the  intestinal  mucosa  incident  to  it  resemble  those  of 
non-specific  enterocolitis,  cholera,  bacillary  (dysenteric)  colitis,  and 
typhoid  fe\'er. 

The  symptoms  are  materially  dift'erent  in  a  series  of  cases,  and 
Breitenbach,'  who  has  extensively  investigated  winter  cholera,  groups 
the  manifestations  of  the  afi^ection  into  the  following  types,  viz. : 

Type  I :  Individual  enjoying  good  health  is  suddenly  taken  with 
severe  colicky  pains,  the  bowel  passages  are  increased  from  two  to 
four  a  day.  The  stools  are  feculent,  very  offensive,  at  first  semisolid, 
finally  water\'.  These  attacks  are  of  short  duration,  seldom  extending 
over  a  period  of  more  than  forty-eight  hours,  at  the  end  of  which 
time  the  patient  may  assume  his  former  well-being.  Because  of  the 
mildness  of  this  type  of  disease  it  seldom  comes  to  the  notice  of  the 
physician. 

Type  2:  Individual  enjoying  good  health  is  suddenly  taken  with 
feeling  of  malaise,  nausea,  and  bilious  vomiting.  With  or  without 
these  acute  stomach  symptoms  at  varying  intervals,  sharp  colicky 
pains  and  a  severe  diarrhea  appear.  The  stools  are  feculent,  but  very 
thin  and  offensive,  and  may  number  from  one  to  twenty  a  day.  Ob- 
jective symptoms  are  practically  negative.  Temperature  is  normal, 
pulse  normal  or  slightly  accelerated.  The  diagnosis  of  this  condition 
is  based  on  the  acute  onset,  the  characteristic  gastro-intestinal  dis- 
turbance, and  the  usual  course  of  the  disease.  Patient  is  never  really 
incapacitated  for  work,  resorts  to  home  remedies,  or  is  subjected  to 
routine  treatment  of  castor  oil  in  large  doses,  followed  by  astringents 
and  bowel  antiseptics,  administered  by  his  medical  adviser,  and  is 
well  in  from  twenty-four  hours  to  three  days. 

Type  3:  This  type  presents  a  most  unusual  array  of  s\mptoms. 
The  cases  in  the  history  of  their  onset  simulate,  \et  in  their 
course  and  mortality  differ  materially  from  typhoid.  Bowel  s\mp- 
toms  vary  in  intensity,  assuming  in  some  few  cases  a  dysenteric  char- 
acter, while  in  others  there  is  constipation.  Temperature  in  this 
class  of  cases  varies  from  98.6°  to  104°  F.,  is  continuous  but  irregular, 
and,  therefore,  in  this  respect,  entirely  at  variance  with  the  remit- 
tent character  of  typhoid.     The  tongue  is  hea\"il\'  furred,  showing  a 

'  "  Choleriform  Diarrhea  of  Cold  Weather,  Winter  Cholera,"  Jour.  .\mer.  Med. 
Assoc,  October  31,  1908. 


88      ACUTE    INFECTIOUS    AND    CONTAGIOUS    DISEASES,    DIARRHEA    IX 

bright  tip  and  margins.  Delirium  in  these  cases  is  of  frequent  occur- 
rence.    The  Widal  and  diazo  reactions  are  negative. 

The  disease  is  diagnosed  from  its  occurrence  during  the  winter 
months,  the  above  symptoms,  and  finding  of  infecting  agents  in  the 
stools,  food,  or  water  being  consumed  by  the  patient  or  community. 

The  mortality  of  winter  cholera  is  rather  high,  and  some  idea  of  the 
seriousness  of  the  affection  may  be  gained  by  a  study  of  the  accom- 
panying table  compiled  by  Breitenbach: 

Deatlis  in  Escanaba,  Michigan,  from  so-called  "Winter  Cholera"  since  i8g8. 

Estimated  Death-rate 

Year.  papulation.  Deaths.  per  loo.ooo. 

i8q8 10.500  10  90 

1899 10,500  8  76 

1900 10.093  25  247 

1901 10.444  15  143 

1902 10.795  22  203 

1903 1 1. 146  18  161 

1904  11-500  37  321 

1905..   11.500  49  426 

1906. .  .  .  11.500  28  243 

1907. .  .  11.500  8  69 

The  treatment  of  winter  cholera  consists  chiefly  in  protecting  the 
community  from  extension  of  the  disease  by  purifying  the  drinking- 
water,  isolating  the  patient,  and  destroying  his  excreta,  and,  when 
the  affection  assumes  a  typhoid  or  dysenteric  character,  treating  the 
sufferer  as  if  he  were  afflicted  with  these  diseases.  In  exceptional 
instances  symptomatic  must  be  substituted  for  curative  measures. 

Breitenbach's  conclusions  regarding  winter  cholera  are  as  fol- 
lows : 

(i)  Winter  cholera  has  no  specific  bacteriologic  patholog>',  and  is  a 
synonym  for  the  more  common  forms  of  bowel  disturbances,  choleri- 
form  in  nature,  occurring  in  cold  weather. 

(2)  The  use  of  this  term  interchangeably  with  the  nomenclature 
of  other  gastro-intestinal  diseases  shows  the  great  need  of  more  exact 
phraseology',  based  on  correct  diagnosis. 

(3)  Meteorologic  conditions  do  not  prove  to  be  the  exciting  cause 
in  these  epidemics  of  winter  cholera,  but  only  as  the  factors  instru- 
mental in  polluting  water  or  milk  are  present  do  these  epidemics  occur. 

(4)  Winter  cholera,  as  typified  by  these  choleriform  manifesta- 
tions of  diarrhea  in  cold  weather,  has  no  exciting  cause  in  the  activity 
of  Pfeift'er's  bacillus,  and  does  not.  therefore,  exemplify  gastro- 
intestinal influenza. 

(5)  Influenza,  with  a  symptomatology'  centering  itself  in  the 
gastro-intestinal  tract,  was  present  during  epidemics  of  winter  cholera, 
but  these  isolated  cases  occurred  during  epidemic  influenza.  Diag- 
nosis in  these  cases  is  established  by  proving  the  presence  of  the 
associated  micro-organism. 

(6)  To  the  end  of  stimulating  a  greater  enthusiasm  in  demanding 
intelligent    and    adequate    sanitary-    reform,    instruction    in    sanitary 


SEPSIS,    DIARRHEA    IN  89 

science  should  demand  a  major  consideration  in  ihe  medical  curricu- 
lum. 

(7)  Legislation  controlling  the  watersheds  and  pre\-enting  con- 
tamination of  public  waters  is  imperative. 

Sepsis,  Diarrhea  in. — This  type  of  diarrhea  is  uncommon,  but 
wiien  present  it  is  difficult  and  often  impossible  to  control,  because  it 
represents  only  one  of  the  manifestations  of  a  local  or  general  sepsis 
which  often  terminates  fatally.  The  loose  movements  may  occur  as 
a  result  of  local  infection  within  the  bowel  directly  through  excretion 
into  the  bowel  of  toxins,  or  reflexly  through  their  effect  upon  the 
nervous  apparatus,  where,  as  the  result  of  single  or  multiple  septic  foci 
located  in  different  parts,  pathogenic  and  pyogenic  micro-organisms 
and  their  toxins  have  become  disseminated  throughout  the  body. 

Acute  sepsis  may  interfere  with  digestion,  produce  an  irritable 
state  of  the  stomach  and  intestine,  and  in  this  way,  together  with  the 
toxins,  cause  moderate  diarrhea  in  one  instance,  or  temporary  paral- 
ysis of  the  bowel  and  constipation  in  another.  While  hemorrhagic 
changes  have  occasionally  been  observed,  proctoscopic  and  sigmoido- 
scopic  examinations  of  the  bowel  at  autopsies  have  shown  that  in  these 
cases  the  mucosa  usually  remains  intact,  w'hich  would  indicate  that 
the  disturbance  responsible  for  the  frequent  movements  is  mainly  of 
toxic  origin.  Some  authorities  have  reported  cases  where  diarrhea 
was  a  serious  or  fatal  complication  in  women  suffering  from  puerperal 
sepsis,  but  Jurgensen  has  never  observed  massive  diarrheas  under 
such  circumstances. 

In  this  class  of  cases  septicemia  and  pyemia  are  generally  caused 
by  streptococci,  staphylococci,  pneumococci,  colon  bacilli,  gonococci, 
etc.  Of  these  inciting  factors,  streptococci  are  encountered  in  about 
75  per  cent.,  and  pneumococci  and  staphylococci  in  10  per  cent.,  of 
the  cases.    Other  micro-organisms  are  met  with  much  less  frequently. 

The  manifestations  reflected  by  gastro-intestinal  disturbances 
consequent  upon  sepsis  are  loss  of  appetite,  nausea,  vomiting,  in 
certain  cases  diarrhea  with  slimy  evacuations  containing  some  blood, 
mild  or  severe  tenesmus,  occasionally  icterus  or  se\ere  bleeding,  and, 
in  rare  instances,  peritonitis,  through  the  formation  of  a  septic  em- 
bolism in  one  of  the  large  vessels  of  the  bowel  or  mesentery. 

Rolleston,  in  summarizing  his  conclusions  relative  to  purpura  in 
infections  complicated  by  diarrhea,  says: 

(i)  Symptomatic  purpura  in  infective  diarrhea  mainly  occurs  on 
the  abdomen  and  chest  of  infants  under  the  age  of  one  year. 

(2)  It  is  usually  a  terminal  phenomenon  in  prolonged  cases. 

(3)  The  prognosis  in  these  cases  is  extremely  grave. 

The  treatment  of  septic  diarrhea  consists  primarily  in  removal  of 
the  foci  by  operation  and  drainage  when  feasible,  but,  when  the 
process  has  become  general,  supportive  measures,  stimulation  of  the 
emunctories,  abundant  intake  of  fluids,  administration  of  calomel, 
creosote,  and  other  antiseptics  and  h>dragogues  to  disinfect  and 
cleanse  the  bowel   are   indicated.       In    the   meanwhile   the   patient's 


90      ACUTE    INFECTIOUS    AND    CONTAGIOUS    DISEASES,    DIARRHEA    IN 

Strength  should  be  sustained  by  a  nutritive  diet,  composed  principally 
of  liquids,  such  as  milk,  whites  of  eggs,  strong  broths,  and  meat  juice, 
and  by  stimulating  the  heart  with  whisky,  strychnin,  or  ammonia. 
Quinin,  gr.  x  (0.60),  three  or  four  times  daily  influences  the  tem- 
perature when  high,  but.  in  the  author's  opinion,  has  no  curative 
effect. 

It  is  generally  agreed  that  the  most  reliable  agent  to  employ  when 
eliminating  bacteria  and  their  toxins  is  a  normal  saline  solution  in 
large  amounts,  administered  in  the  form  of  both  hypodermoclysis 
and  high  enemata,  which  serve  the  double  purpose  of  diluting  the 
blood  and  cleansing  the  bowel  of  its  irritating  contents.  The  solution 
should  be  used  as  frequently  and  in  as  large  amounts  as  the  patient 
will  stand. 

When  the  patient  is  in  a  critical  condition  and  surgical  inter- 
vention for  any  reason  is  impracticable,  antistreptococcic  serum  should 
be  injected,  although  the  results  from  it  have  thus  far  been  disap- 
pointing. Anders  recommends  the  employment  at  first  of  1000  units 
of  jMarmorek's  serum  daily  or  at  longer  intervals  later,  and  says 
that  Pearce  prefers  polyvalent  serum,  which  seemingly  gives  better 
results. 

In  pyemia,  in  addition  to  the  above  treatment,  the  exhausting 
sweats  are  best  controlled  by  belladonna,  gr.  |  (0.008);  atropin, 
gr.  TTo  (0.0005);  or  agaricin,  gr.  i  to  j  (0.008-0.016),  administered 
at  night  or  oftener  if  indicated. 

Erysipelas,  Diarrhea  in. — In  this  affection  diarrhea  is  very  often 
an  annoying  symptom,  and  the  evacuation  contains  more  or  less 
blood,  owing  to  the  fact  that  the  bowel  at  times  becomes  congested 
and  ulcerated.  Tillmann  holds  that  the  appearance  of  the  bowel 
resembles  that  sometimes  seen  in  cases  of  extensive  burns. 


CHAPTER   VII 

MISCELLANEOUS    INFECTIOUS    DISEASES,    DIARRHEA    IN 

TROPICAL  DIARRHEAS:  COCHIN-CHINA  DIARRHEA,  SPRUE,  HILL-DIAR- 
RHEA, DIARRHEA  ALBA,  PSEUDODYSENTERY,  EL  BICHO  DIAR- 
RHEA, ANTHRAX,  MALARIA,  TYPHUS  FEVER,  PLAGUE,  GLANDERS, 
SUTIKA,   INTESTINAL   MYIASIS,   PELLAGRA,   ACTINOMYCOSIS 

Tropical  Diarrheas :  Cochin-China  Diarrhea,  Sprue,  Hill-Diarrhea, 
Diarrhea  Alba,  Pseudodysentery,  and  El  Bicho  Diarrhea. — Under  the 
al)()\'(.'  caplicjns  llie  auihor  will  discuss  certain  t\pes  of  diarrhea  com- 
mon to  tropical  countries,  which  are  probably  caused  by  entamebic 
or  bacillary  infection,  but  which  are  still  considered  as  distinct  afifec- 
tions  by  some  of  our  best  authorities. 

Entamebic  and  bacillary  colitis  will  not  be  discussed  here  because 
they  have  received  full  consideration  in  other  chapters  set  apart  for 
the  purpose. 

Diarrhea  is  prevalent  in  all  tropical  countries,  and  a  number  of 
reasons  can  be  advanced  to  explain  why  this  is  so.  In  many  instances 
the  majority  of  the  inhabitants  of  tropical  lands  are  rendered  amen- 
able to  infection  because  of  their  lowered  resistance,  brought  about 
through  unhealthy  unhygienic  surroundings,  insufficient,  poor,  or 
improperly  prepared  food,  and  the  intense  heat  and  high  humidity  of 
such  countries.  Tropical  diarrhea  may  result  from  infection  of  the 
individual,  his  food  or  water,  by  flies,  gnats,  fleas,  mosquitos,  and 
other  carriers  of  infection  which  thrive  in  warm  countries  where  the 
air  contains  considerable  moisture.  The  chief  cause  of  the  loose 
movements  in  this  class  of  cases  is  often  traceable  to  water  pollution, 
because  the  people  are  ignorant  or  careless  as  to  hygienic  conditions, 
and  take  but  few  if  any  precautions  toward  keeping  their  water- 
supply  from  becoming  infected  by  decayed  vegetable  and  animal 
products,  the  excreta,  etc. ;  nor  do  they  appreciate  the  importance  of, 
or  take  precautionary  measures  to  prevent,  extension  of  the  infection 
from  afflicted  to  healthy  individuals  through  proper  disposition  of 
their  refuse. 

The  enormous  benefits  to  be  derived  by  preventive  measures 
in  diarrhea  and  other  tropical  diseases  has  been  demonstrated  in 
Cuba,  Porto  Rico,  and  the  Panama  Canal  Zone  since  they  were  taken 
over  by  our  government. 

Again,  a  number  of  infective  and  parasitic  diseases  which  induce 
diarrhea  are  endemic  in  hot  countries,  but  are  seldom  encountered 
in  the  northern  part  of  the  United  States  and  in  cold  countries,  except 
where  infected  individuals  come  from  tropical  countries,  and  persons 
become  infected  by  contact  with  them. 

91 


92  MISCELLANEOUS    INFECTIOUS    DISEASES,    DIARRHEA    IN 

Dysentery  and  certain  parasitic  affections  have  for  a  long  time  been 
encountered  in  the  Southern  States,  particularly  in  hot  and  swampy 
districts,  but  it  is  only  in  recent  years,  since  our  soldiers,  sailors, 
and  citizens  began  returning  from  Cuba,  Porto  Rico,  Panama,  and  the 
Philippines,  that  these  diseases  made  their  appearance  in  the  north. 

While  diarrhea  consequent  upon  simple  enteritis  or  enterocolitis 
may  be  encountered  in  hot  as  in  other  countries,  in  most  instances  the 
loose  movements  are  traceable  to  an  intestinal  infection  of  some 
kind  or  to  atmospheric  conditions. 

Tropical  diarrhea  has  been  described  by  different  authorities 
under  the  captions  of  Sprue,  Psilosis  Lingua  et  Mucosa  Intestini, 
Aphthae  Tropica,  Cochinchinitis,  Hill-diarrhea,  Pseudodysenten,-, 
and  White  Flux  (Diarrhea  Alba),  but,  from  the  author's  study  of 
the  subject,  it  would  appear  that  sprue  (psilosis),  pseudodysenter\', 
Cochin-China  diarrhea,  and  hill-diarrhea  have  individual  character- 
istics, and  that  other  so-called  types  of  tropical  diarrhea  are  varia- 
tions of  these  affections. 

Cochin-China  Diarrhea. — This  disease  is  so  named  because  of  its 
great  prevalence  in  Cochin-China,  where  it  has  been  responsible  for 
a  great  many  deaths,  particularly  during  such  epidemics  as  occurred 
in  1868  and  1872.  Cochinchinitis,  or  an  affection  with  the  same 
symptom-complex,  has  also  been  encountered  with  considerable  fre- 
quency in  India,  southern  China,  Borneo,  the  Antilles,  the  Philip- 
pines, and  South  America.  In  these  countries  the  whites  are  more 
susceptible  to  the  disease  than  the  yellow  race,  and  children  are  more 
frequently  attacked  than  adults,  among  whom  the  mortality  is  said 
to  be  15  to  30  per  cent. 

The  disease  is  considered  to  be  infectious,  and  is  supposed  to 
follow  the  ingestion  of  unhealthy  water,  which  causes  an  enterocolitis. 

The  Strongyloides  intestinalis  are  often  found  in  great  numbers 
in  the  stools  of  this  class  of  patients,  and  were  believed  to  be  the 
cause  of  the  disease  until  recent  investigations  demonstrated  that 
they  have  but  little  if  any  pathologic  significance  in  this  connection. 
The  author  believes  that  Cochin-China  diarrhea  is  due  in  some  in- 
stances to  entamebic  {Entamceba  histolytica)  and  in  others  to  bacillary 
(Shiga,  Flexner,  Strong  bacilli,  etc.)  infection,  and  that  the  Strongy- 
loides intestinalis  simply  aggravate  the  condition. 

In  two  blood  examinations  by  Lemoine  small  protoplasmic  crowns 
with  a  refractive  capsule,  vesicular  in  shape,  containing  granules  and 
an  indistinct  nucleus,  were  found.  They  were  larger  than  red  blood- 
cells,  of  constantly  changing  shape  (the  ameboid  movements  being 
observable  for  several  hours),  and  he  regarded  them  as  the  cause 
of  Cochinchinitis.  Owing  to  the  absence  of  cultures  and  transmis- 
sion, their  etiologic  connection,  if  any,  was  not  established.  The 
disease  has  also  been  attributed  to  other  micro-organisms  and  para- 
sites, but  authors  differ  as  to  the  organisms  responsible  for  it.  Le- 
moine, with  reason,  says  that  "doubtlessly  the  diarrhea  of  hot  climates 
is  merely  a  symptom-complex,  and  it  is  probaljlc  that  certain  enteric 


SPRUE,    PSILOSIS    LIXGU.B    ET    MUCOS.E    IXTESTINI  93 

affections  grouped  under  this  heading  are  due  to  various  parasites, 
such  as  protozoa,  lambHa,  megastoma  of  Cohnheim,  trichomonas,  and 
even  all  sorts  of  bacilli." 

The  symptom-com[)lex  of  Cochin-China  diarrhea  is  similar  to  that 
of  catarrhal  enterocolitis  except  that  profound  anemia  characterizes 
the  disease.  The  movements  are  frecjuent  and  fluid,  but  do  not  con- 
tain pus  or  blood,  and  because  of  this  and  the  absence  of  abdominal 
tenderness  some  authors  hold  that  Cochinchiniti-^  shf)ul(l  not  be  con- 
fused with  tropical  dysentery. 

But  little  is  known  concerning  the  pathology  of  this  condition 
further  than  that  there  is  congestion  of  the  mucosa,  swelling  of  the 
intestinal  glands,  which  are  covered  with  mucus,  and  a  resemblance 
to  catarrhal  enteritis. 

Sprue,  Psilosis  Linguae  et  Mucosae  Intestini. — This  form  of  tropi- 
cal diarrhea  is  particularly  common  to  India  and  China,  and  differs 
principally  from  others  in  that  the  mucosa  of  the  tongue  and  mouth 
early  become  exceedingly  sensitive  and  ulcerated,  from  which  circum- 
stance the  disease  takes  the  name  of  "sprue,"  and  the  patient  suffers 
from  indigestion,  diarrhea,  emaciation,  anemia,  and  may  die  from 
general  weakness. 

The  etiology  of  psilosis,  or  sprue,  is  unknown,  but  the  authorities 
who  have  studied  it  most  concede  its  infective  nature,  although  the 
inciting  specific  organism  has  not  been  discovered. 

The  attack  is  acute,  frequently  follows  overeating;  shortly  the 
mouth  and  tongue  become  dr\-,  swollen,  glistening,  sore,  frequently 
furrowed,  and  the  saliva  acid;  manifestations  which  are  quickh- 
followed  by  melancholia,  indigestion,  distress,  tympanites,  vomiting. 
and  diarrhea  with  copious,  foamy,  offensive,  pale-colored  evacua- 
tions, which  at  the  outset  are  greenish.  The  disturbances  of  the 
mouth  and  bowel  usually  occur  and  disappear  about  the  same  time, 
but  the  suffering  from  the  former  is  much  more  distressing  than  the 
latter  because  of  the  pain  incident  to  eating,  talking,  and  swallowing. 

Temporary'  improvement  follows  treatment,  but  the  patient  has 
frequent  relapses,  the  disease  usually  becomes  chronic,  the  sufferer 
develops  a  deplorable  anemia,  and  becomes  emaciated  through  the 
great  loss  of  weight  (25  to  50  pounds  in  some  instances). 

The  diarrhea  is  not  severe  in  the  incipient  stages,  since  the  patient 
rarely  has  more  than  three  evacuations  daily,  but  these  are  soft, 
exceedingly  copious,  and  occur  early  in  the  morning.  Later,  as  the 
ulcerated  condition  of  the  buccal  cavity  becomes  more  serious,  their 
frequency  is  increased,  the  patient  rapidly  becomes  exhausted,  and 
assumes  an  anemic,  pasty,  characteristic  appearance. 

A  diagnosis  is  comparatively  easy,  although  sprue  has  been  con- 
fused with  entamebic  and  bacillan.-  colitis  (dysenter\),  cholera,  and 
other  severe  types  of  intestinal  infection,  but  this  is  difficult  to  under- 
stand because  a  comparison  of  the  manifestations  of  it  with  such  dis- 
eases readily  shows  their  dissimilarity,  and  in  sprue  the  ulcerated 
condition  of  the  mouth   is  pathognomonic.      Lemoine  says  there  is 


94  MISCELLANEOUS    INFECTIOUS    DIS1£ASES,    DIARRHEA    IN 

often  a  marked  analogy  between  this  condition  and  mucomembranous 
enterocolitis,  but  such  a  relation  seems  improbable  to  the  author. 

Bacteriologic  examination  of  the  feces  is  useful,  since  the  finding 
of  the  specific  micro-organisms  of  other  diarrheal  diseases  would  ex- 
clude sprue,  and  their  absence  would  indicate  this  condition. 

Hill-diarrhea. — This  form  of  loose  movements  is  frequently  en- 
countered in  India  and  South  America,  or  in  Europeans  who  have 
lived  in  these  countries.  It  is  met  with  in  persons  who  at  one  time 
or  another  have  resided  upon  hills  or  mountains  at  an  elevation  of 
6000  feet  or  more,  and  is  supposed  to  result  from  a  sudden  change  of 
temperature  and  diminished  atmospheric  pressure  (no  specific  cause 
having  been  discovered,  though  it  is  probably  a  parasitic  or  a  bac- 
terial disease),  which  leads  to  chronic  intestinal  catarrh  and  diar- 
rhea, but  Cantlie  thinks  the  condition  arises  from  fine  particles  of 
gravel  contained  in  the  water.  This  aflfection  may  occur  at  any  age 
and  in  either  sex,  but  is  more  common  in  men  than  women,  is  rarely 
fatal,  and  often  becomes  chronic  unless  the  patient  returns  to  a  lower 
altitude. 

Persons  afflicted  with  hill-diarrhea  suffer  from  anorexia,  malaise, 
flatulency,  dyspepsia,  and  a  diarrhea  wherein  the  movements  are 
abundant,  colorless,  occur  most  often  in  the  early  morning  hours, 
and  have  a  frothy  covering  resembling  that  of  sprue. 

Diarrhea  Alba  (Diarrhea  Chylosa,  Celiac  Disease). — This  type  of 
diarrhea,  which  has  been  described  and  designated  celiac  disease  by 
Gee,  may  occur  at  any  age,  but  is  encountered  most  frequently  in 
children  under  five,  and  apparently  results  from  a  sort  of  combina- 
tion between  intestinal  indigestion  and  catarrh,  although  parasites 
(Filaria  sanguinis  hominis)  have  been  observed  in  connection  with 
and  may  produce  it.  This  condition  may  be  met  with  in  any  country, 
and  because  of  its  close  resemblance  has  been  confused  with  sprue 
and  the  hill-diarrhea  of  India.  Diarrhea  alba  comes  on  slowly,  and  is 
characterized  by  emaciation,  weakness,  pallor,  dropsy,  tired  feeling, 
boggy  sensation  on  abdominal  palpation,  a  moderately  distended 
abdomen,  and  intestinal  ulcers  (unexplainable)  have  been  observed. 
The  mortality  is  high  in  these  cases,  but  when  the  patient  recovers 
he  shows  a  manifest  weakness  in  the  legs  and  is  often  unable  to 
jump. 

The  stools  here  differ  from  miscellaneous  diarrheas,  in  that  they 
are  very  bulky  and  are  more  abundant  than  the  amount  of  food  con- 
sumed would  warrant,  are  soft,  light  colored  (owing  to  the  absence  of 
bile),  frothy,  have  an  offensive  odor,  and  closely  resemble  gruel  or 
oatmeal  porridge. 

The  diagnosis  is  based  upon  the  white  and  foani>-  character  of  the 
evacuations  and  finding  of  the  filaria. 

The  prognosis  in  tropical  diarrheas,  excepting  entamebic  and 
bacillary,  is  good  in  middle-aged  and  in  youthful  indixiduals,  but  gra\e 
in  infancy  and  old  age. 

Treatment  of  Tropical  Diarrheas. — The  therapeutic  measures  em- 


DIARRHEA    ALBA    (DIARRHEA    CHYLOSA,    CELIAC    DISEASE)  95 

ployed  in  the  handling  of  patients  afflicted  with  Cochin-China,  sprue, 
hill-,  and  pseudodysenleric  diarrhea  are  about  the  same,  except  in 
hill-diarrhea,  where  it  is  advisable  at  the  earliest  opportunity  to 
remove  the  patient  from  a  high  to  a  lower  altitude.  The  most  essen- 
tial thing  in  the  treatment  is  to  protect  him  from  the  hot  sun,  keep  him 
cool,  resting  in  bed,  and  to  see  that  he  neither  eats  nor  drinks  contami- 
nated water  or  food.  On  account  of  the  ulcerated  condition  of  the 
mouth  and  irritable  state  of  the  intestine,  coarse  foods  are  contra- 
indicated,  and  the  patient  should  be  sustained  for  a  short  or  long 
time,  according  to  indications,  on  milk,  eggs,  broths,  and  meat- 
juices,  but  warm  milk  in  abundance  causes  the  least  discomfort  and 
affords  the  necessary  nourishment  when  taken  in  small  amounts  at 
short  intervals.  When  after  a  few  weeks  the  buccal  condition  im- 
proves, and  the  stools  become  normal  or  nearly  so,  the  diet  may  be 
gradually  increased  until  a  fair  amount  of  solids  are  taken.  It  is 
necessary  for  the  patient  to  be  cautious  as  regards  his  diet  for  a  con- 
siderable time  after  an  attack,  as  relapses  are  prone  to  occur  when  the 
food  is  improperly  cooked  or  he  eats  indiscriminately  of  beef,  solids, 
raw  vegetables,  pickles,  or  drinks  abundantly  of  alcoholic  stimulants. 
When  milk  disagrees,  this  can  often  be  corrected  by  mixing  it  with 
lime-  or  seltzer  water. 

The  majority  of  patients  recover  under  a  strict  milk  diet,  while 
medical  agents  avail  but  little,  further  than  to  control  manifestations 
which  suddenly  become  pronounced.  At  the  beginning  a  laxative  or 
calomel  may  be  prescribed  to  advantage  when  biliousness  or  intes- 
tinal putrefaction  are  present,  and  Manson  advocates  intramuscular 
injections  of  arsenic  and  iron  to  relieve  the  anemia. 

Much  can  be  done  to  add  to  the  patient's  comfort  by  spraying 
the  highly  sensitive,  inflamed,  and  ulcerated  areas  of  the  mouth  and 
pharynx  with  a  4  per  cent,  solution  of  eucain  to  anesthetize  them, 
and  then  painting,  spraying,  or  bathing  them  with  silver  nitrate,  5 
per  cent.,  or  other  mild  astringent  or  antiseptic  solutions. 

Stimulation  and  nutrient  rectal  enemata  are  indicated  when  food 
cannot  be  taken  by  mouth  and  the  patient  is  rapidly  being  exhausted. 
A  fruit  diet  has  been  recommended,  but,  reasoning  from  analogy  in 
other  diarrheas,  this  would  seem  to  be  bad  practice. 

Diarrhea  is  best  controlled  by  flushing  the  colon  with  soothing, 
antiseptic,  and  stimulating  solutions,  and  by  the  administration  of 
opium  in  small  doses  sufficiently  often  to  reduce  the  evacuations, 
solidify  the  feces,  relieve  pain,  and  secure  needed  rest  and  sleep. 
But  when  these  measures  fail,  append icosfomy  or  cecostomy  and 
through-and-through  irrigation  are  indicated. 

The  treatment  of  diarrhea  alba  is  symptomatic  in  so  far  as  the 
diarrhea  is  concerned,  and  consists  in  the  administration  of  opiates, 
astringents,  and  antiseptics;  but  when  there  is  reason  to  belie\e  that 
the  trouble  is  due  to  filariasis,  thymol  ,  gr.  ij  to  v  (0.12-0.30),  daily, 
has  proved  most  efficacious,  although  as  yet  no  effective  specific 
has  been  discovered. 


96  MISCELLANEOUS    INFECTIOUS    DISEASES,    DIARRHEA    IN 

Pseudodysenteric  diarrhea  is  a  type  of  loose  movements  encoun- 
tered in  hot  countries,  particularly  Sumatra,  wherein  the  evacuations 
have  a  dysenteriform  appearance,  but  upon  examination  are  found 
to  contain  neither  entameba  nor  Shiga  bacillus,  though  bacilli  are 
present  which  become  agglutinated  through  the  patient's  serum. 
The  cultures  resemble  but  are  differentiated  from  Shiga  bacillus  by 
their  mannite,  and  are  not  rendered  immune  by  the  Shiga  serum. 

Barmann-Schiiffner  have  observed  6  cases  in  Sumatra,  and  state 
that  on  the  basis  of  these  findings  it  is  justifiable  to  interpret  these 
isolated  bacteria  as  pseiidodysentery  bacilli.  Probably  the  disease,  if 
not  due  to  Shiga  bacillus,  is  caused  by  bacilli  of  the  Flexner,  Hiss,  or 
Harris  types. 

The  symptoms,  diagnosis,  and  treatment  of  this  condition  so  closely 
resemble  those  of  other  tropical  diarrheas  as  to  make  their  further 
discussion  superfluous. 

Anthrax,  Diarrhea  in. — Anthrax  may  be  accompanied  by  diar- 
rheal manifestations,  but  this  is  exceptional,  and  when  there  are 
accelerated  movements  they  are  few  in  number,  not  of  an  exha,ust- 
ing  type,  rarely  contain  pus  and  blood,  and  are  of  slight  importance 
as  regards  the  prognosis,  but  are  valuable  from  a  diagnostic  standpoint. 
When  the  bacilli  in  the  form  of  immotile  sporiferous  rods  are  detected 
a  diagnosis  secondary-  to  anthrax  is  justifiable. 

Iwaschenzow  has  called  attention  to  an  epidemic  of  intestinal 
anthrax  (7  cases)  studied  by  him  in  Russia  in  the  summer  of  1909, 
when  all  of  the  patients  died.  Three  of  the  cases  had  been  misinter- 
preted as  ileus,  on  account  of  collapse,  obstipation,  and  meteorism 
in  the  lower  abdominal  region.  The  observ^er  directs  attention  to 
one  symptom  that  is  practically  constant  (5  of  7  cases),  namely,  the 
presence  of  free  fluid  in  the  lower  abdominal  cavity.  The  diagnosis 
was  rendered  during  life  in  only  i  of  7  cases,  and  in  this  instance  it 
was  based  on  the  history. 

The  treatment  of  external  anthrax  consists  in  excising  the  pustule, 
and  when  this  is  not  feasible,  in  applying  to  or  injecting  into  it  weak 
solutions  of  carbolic  acid;  but  in  the  internal  variety,  where  the  dis- 
ease attacks  the  intestine  and  causes  diarrhea,  there  is  no  hope  for 
the  patient,  and  he  should  be  treated  symptomatically  and  made 
comfortable  while  he  lives. 

Malaria,  Diarrhea  in. — Malaria  generally  runs  its  course  without 
any  serious  bowel  disturbances,  but  in  exceptional  instances  there  are 
evidences  of  a  catarrhal  inflammation  of  the  intestine,  when  diarrhea 
may  prevail  to  a  slight  degree,  or  in  cases  where  the  disease  is  malignant 
and  anemia  is  prominent  the  evacuations  may  be  very  frequent, 
watery,  and  resemble  those  of  cholera. 

Typhus  Fever,  Diarrhea  in. — Typhus  fever  is  most  often  com- 
plicated by  constipation,  but  moderate  diarrhea  may  occur  in  the 
eruptive  stages. 

Plague  (Black  Death),  Diarrhea  in. — Plague  is  an  infectious  and 
often  fatal  disease  caused  Ijy  the  Bacillus  pest  is  bubonicce;  it  is  quite 


SUTIKA  (puerperal  DIARRHEA  OF  BENGAL),  DL\RRHEA  IX 


97 


common  in  the  far  East,  occasionally  encountered  in  epidemic  form 
in  European  countries,  and  cases  have  been  observed  in  the  United 
States,  particularly  in  San  Francisco,  where  31  cases  were  studied  in 
the  early  part  of  1901.  The  disease  is  most  virulent  during  summer 
and  fall,  and  is  met  with  in  unhygienic  communities,  and,  according 
to  its  severity,  may  be  characterized  by  dermatologic  manifestations, 
glandular  enlargements,  pneumonia,  septicemia,  or  severe  intes- 
tinal involvement.  In  the  last  type  there  are  frequent  hemorrhages, 
severe  abdominal  pain,  and  the  patient  suffers  from  what  has  been 
designated  "bloody  diarrhea." 

Glanders,  Diarrhea  in. — Human  glanders  is  characterized  by 
nasal  ulceration,  but  sometimes  the  lesions  reach  the  mucosa  of  the 
stomach  and  intestines  and  cause  l)lf)orly  e\aruations  and  diarrhea. 

Sutika  (Puerperal  Diarrhea  of  Bengali,  Diarrhea  in. — Sutika  is  a 
complication  of  the  plague,  fully  discussed  in  Pearse's  report  of  the 
epidemic  in  Calcutta  in  the  years  1904-05.  This  condition  appears 
with  fever  and  very  frequent  movements  in  connection  with  child- 
birth, and  the  extent  to  which  it  prevails  and  the  dangers  from  it  are 
indicated  by  the  following  statistics  (Pearse): 

During  a  single  year  (1906-07)  there  occurred  in  Calcutta  228 
deaths  from  sutika.  as  compared  to  196  deaths  from  puerperal  fever, 
and  80  deaths  in  the  course  of  labor.  The  total  number  of  deliveries 
registered  in  Calcutta  is  about  17,000  per  year,  and  of  this  number 
over  1.3  per  cent,  of  the  puerperal  women  succumb  to  sutika. 

So  little  is  known  of  this  remarkable  disease  that  the  author  will 
rely  chiefly  upon  Pearse  for  a  description  of  it: 

Sutika  is  characterized  by  the  following  symptoms:  In  the  course 
of  the  first  two  weeks  after  deliver^-,  sometimes  later,  a  diarrhea  makes 
its  appearance  which  is  usually  not  associated  with  pain.  The  number 
of  stools,  which  are  watery,  sometimes  fermenting,  but  contain 
neither  mucus  nor  blood,  varies  between  five  and  fifteen  daily. 
In  a  certain  number  of  the  cases  symptoms  of  dyspepsia  are  noted, 
and  anorexia  is  present  in  practically  all.  On  the  other  hand,  there 
is  neither  vomiting,  painful  coughing,  or  anything  to  suggest  disturb- 
ance in  the  pelvic  region.  Parallel  with  the  diarrhea  there  develops 
fever,  with  an  irregular  course.  The  patients  rapidly  lose  flesh,  suf- 
fer from  general  prostration,  and  death  takes  place  from  exhaustion. 
Toward  the  terminal  period  there  often  develops  edema  of  the  lower 
extremities. 

The  course  of  the  disease  is  somewhat  \ariable:  sometimes  it  is 
rather  rapid,  the  patient  succumbing  within  a  few  months;  in  other 
cases  the  condition  drags  along  for  a  year  or  longer.  The  average 
duration  of  the  diarrhea  is  from  five  to  eight  months.  The  condition, 
which  has  also  been  noted  in  other  Bengal  cities,  attacks  women  of 
all  ages,  and  is  observed  with  the  same  frequency  among  the  Hindoo 
population  as  among  Mohammedans.  On  the  other  hand,  it  has 
not  apparently  been  demonstrated  in  Europeans.  The  diagnosis 
is  not  difficult,  but  the  pathogenesis  of  the  disease  remains  entirely 
7 


98 


MISCELLANEOUS    INFECTIOUS    DISEASES,    DIARRHEA    IN 


obscure.  It  is  certain,  however,  that  we  are  not  dealing  with  ordinary 
puerperal  fever  nor  with  dysentery,  and  there  is  no  apparent  reason 
for  referring  the  trouble  to  tuberculosis. 

Intestinal  Myiasis,  Diarrhea  in. — Occasionally  maggots  (screw- 
worms)  find  their  way  into  the  colon,  causing  extensive  ulceration  of 
the  mucosa  through  their  boring  into  it  at  various  points,  a  condi- 
tion usually  accompanied  by  diarrhea,  pus,  and  blood  in  the  stools. 
The  disease  is  common  to  tropical  countries,  but  has  seldom  been  en- 
countered here.  Einhorn  has  reported  (personally  to  the  author)  a 
most  interesting  case  of   colonic  myiasis  (Fig.  24),  where  the  bowel 


J  limes 


\ 


f^/atar^l 


Fig.  24.- — Intestinal  myiasis.  Note  normal  size  of  maggots  on  the  right,  and  one 
magnified  three  times  on  the  left.  Detected  in  the  feces  of  a  patient  suffering  from 
intestinal  indigestion. 


apparently  contained  thousands  of  maggots,  and  Schlesinger  and 
Weichselbaum^  studied  a  case  of  extensive  colonic  ulceration  associated 
with  colonic  atony  and  recurring  fecal  impaction,  w'hich  they  regarded 
as  due  to  intestinal  myiasis. 

The  maggots,  or  larvae,  which  are  formed  from  eggs  laid  upon 
wounds  or  the  edges  of  orifices  by  flies  {Derniatobia  cyaniventris)  are 
"white,  more  than  h  inch  in  length  (Fig.  24),  and  formed  of  twelve 
segments,  carrying  circles  of  minute  spirally  arranged  spines,  which 
give  the  creature  a  screw-like  appearance"  (Manson-).  They  pene- 
trate deeply  into  whatever  tissue  they  attack,  and  cause  excruciating 
pain  or  even  death  when  permitted  an  uninterrupted  course. 

McCampbell   and   Cooper'   reported   a   unique   case  of  intestinal 

1  Wien.  Klin.  Wochenschr.,  January  9,  1901. 

2  Tropical  Diseases,  4th  ed.,  iqoy. 

3  Jour.  Amer.  Med.  Assoc,  October  g,  iqoq. 


PELLAGRA,    DL\RRHEA    IX  99 

myiasis  due  to  infection  from  three  species  of  dipterous  larva,  which  is 
the  only  instance  where  the  disease  was  caused  by  a  mixed  infection. 

The  symptoms  of  colonic  myiasis  resemble  those  of  other  types 
of  ulceration  in  this  region,  but  are  not  likely  to  be  diagnosed  unless 
the  maggots  are  microscopically  seen  in  the  feces  or  are  accidentally 
discovered  when  the  excreta  is  being  examined  for  other  infective 
agents. 

The  treatment  consists  in  keeping  the  insects  fflies)  from  the 
patient,  and  in  irrigating  the  colon  with  as  strong  a  solution  of  car- 
bolic acid,  chloroform,  or  turpentine  as  the  patient  can  stand. 

El  Bicho  Diarrhea. — A  severe  and  common  type  of  diarrhea, 
known  as  El  Bicho,  is  encountered  in  Brazil  (particularly  in  the  trop- 
ical marshy  districts),  and  is  thought  to  be  a  form  of  dysentery.  The 
Indians  of  the  hills  suffer  from  it  as  soon  as  they  descend  to  the  low 
sections  of  the  Republic.  In  these  cases  the  rectum,  and  colon  exhale 
a  putrid  odor,  the  patient  complains  of  fever,  sometimes  sloughing 
of  the  bowel  is  extensive,  and  diarrhea  is  extremely  depressing. 

Pellagra,  Diarrhea  in. — Alany  theories  have  been  advanced  to 
explain  ilic  L-iiol(jg\'  of  pellagra,  but  its  cause  is  still  unknown.  Any 
and  all  parts  of  the  gastro-intestinal  tract  may  be  disturbed  in  pel- 
lagra, and  manifestations,  as  gastralgia,  pyrosis,  nausea,  vomiting,  gas 
distention,  diarrhea,  coated  tongue,  and  lack  of  appetite,  are  quite 
common,  but  the  chief  symptoms  in  a  typic  case  are  a  sore  mouth, 
indigestion,  and  diarrhea. 

The  part  played  by  loose  movements  in  pellagra  has  been  con- 
cisely given  by  Roberts,^  viz.:  "The  diarrhea  usually  precedes  the 
dermatitis,  but  it  may  occur  simultaneously,  and  Fritz  has  noticed 
that  it  is  common  for  the  two  to  appear  together  in  those  whose  work 
keeps  them  in  the  sun.  It  also  shows  that  the  diarrhea  is  the  symp- 
tom of  a  systemic  morbid  process.  The  diarrhea,  stomatitis,  and 
dermatitis  reach  their  culmination  together  during  the  outbreak. 
The  diarrhea  comes  gradually,  lasts  about  a  month  all  told,  disap- 
pearing gradually  as  it  came.  In  Tucker's  55  collected  cases,  diar- 
rhea was  present  in  54,  with  remissions  in  the  diarrhea  in  36  cases, 
and  diarrhea  alternating  with  constipation  in  30  cases.  All  my  cases 
except  one  had  diarrhea,  and,  without  exception,  the  more  severe 
the  diarrhea,  the  greater  the  prostration  and  exhaustion  and  the  more 
apparently  severe  the  pellagra.  In  some  pellagrins  the  flux  is  so 
severe  as  to  merit  the  title  of  'diarrheic  pellagra.'  The  Eg\-ptian  cases 
of  Sandwith  seem  to  have  less  diarrhea  than  either  the  Italian  or 
American.  Out  of  166  cases,  the  bowels  in  103  were  normal,  9  had 
slight  constipation,  46  with  slight  diarrhea,  and  8  with  excessive  diar- 
rhea. 

"In  the  height  of  the  spring  attack  the  number  of  stools  in  the 
twenty-four  hours  varies  from  six  to  thirty,  ten  to  twenty  being  an 
average.  In  my  own  experience  the  number  of  stools  is  influenced 
neither  by  rest  nor  food,  and  the  number  is  as  great  in  the  night  as 

*  Pellagra,  191 2. 


lOO  MISCELLANEOUS    INFECTIOUS    DISEASES,    DIARRHEA    IN 

in  the  day,  and  often  worse  from  3  to  9  o'clock  in  the  morning.  In 
the  early  part  of  the  attack  and  in  the  initial  stage  of  the  disease  the 
diarrhea  is  more  spasmodic  in  character  and  with  far  more  peristaltic 
activity,  so  that  the  patient  complains  of  abdominal  pain  and  griping 
like  a  colic  from  indigestion.  The  stools  at  this  time  are  thicker, 
contain  more  mucus  and  endothelial  cells,  the  pellagrous  odor  is  not 
so  pervasive,  and  the  stools  do  not  come  so  freely  as  in  the  latter 
stages.  At  this  time  they  may  be  tinged  with  blood,  though  not  so 
commonly  as  in  acute  dysentery.  They  vary  from  gray  and  light 
brown  to  green  in  color. 

"In  the  later  stages  of  the  disease  the  diarrhea  assumes  a  more 
serous  character,  is  more  persistent,  and  far  less  amenable  to  treat- 
ment. It  is  almost  a  pure  watery  stool,  usually  of  a  light-green  color, 
occasionally  almost  clear.  At  this  time  the  acute  phase  of  the  dis- 
ease may  develop,  and  the  diarrhea  precede  the  delirium,  and  fore- 
shadows marasmus  and  the  approach  of  death.  As  the  serous  dis- 
charges increase,  distention  develops  and  paresis  of  the  intestinal  walls 
occurs.  Rectitis,  hemorrhoids,  and  anal  fissures  add  to  the  cachexia 
and  distress.  As  a  rule,  the  mild  cases  do  not  develop  a  severe  diar- 
rhea, and  the  diarrhea  ceases  as  the  attack  recedes.  The  diarrhea 
may  be  the  only  symptom  of  the  fall  exacerbation  and  may  last  for  only 
a  few  days;  in  other  cases,  after  the  first  spring  attack,  the  bowels 
are  always  relaxed,  and  two  to  four  stools  a  day  are  common.  In 
the  cases  with  constipation  the  attack  is  mild  and  short,  and  the 
disease  progresses  slowly.  The  life  of  the  pellagrin  is  prolonged 
in  inverse  proportion  to  the  severity  and  the  persistence  of  the 
diarrhea. 

"As  the  disease  advances  the  entire  alimentary  tract  becomes 
inflamed;  gastritis,  enteritis,  colitis,  and  rectitis  are  the  foundations 
for  gastric  and  intestinal  ulceration,  with  blood,  mucus,  pus,  and 
increased  putrefaction  and  fermentation.  At  this  stage  indicanuria  is 
common.  Absorption  is  interfered  with,  and  there  is  an  increase  in 
undigested  food  materials,  especially  fats,  starch  granules,  plant 
cells,  and  muscle-fibers.  The  stools  are  acid,  as  a  rule,  and  gaseous, 
looking  as  if  they  had  been  whipped,  so  numerous  are  the  air-bubbles. 
Under  the  microscope  there  is  an  increase  in  the  fat-globules,  due 
probably  to  a  decrease  in  the  bile  and  pancreatic  juice.  If  the  stool 
in  pellagrous  diarrhea  is  put  in  a  bottle  or  graduate  and  allowed  to 
stand  for  several  hours  it  separates  into  three  lasers — (i)  above  is 
the  aqueous  portion,  serous  in  character,  often  colored  a  light  yellow; 
(2)  below  this  a  thick  gray  layer,  composed  of  mucus,  pus,  and  occa- 
sionally blood-cells;  (3)  a  heavy  layer  below,  dark-brown  or  green  in 
color,  and  composed  chiefly  of  waste  matter  from  the  food  or  ordinary 
fecal  matter,  in  which  is  found  clinging  mucus  that  lias  not  separated. 
J.  D.  Long,  in  his  admirable  studies,  found  ammonium  and  magne- 
sium phosphate  crystals,  fatty  acid  crystals,  calcium  oxalate,  choles- 
terin  plates,  and  fungi." 

The  patholoiiy  of  intestinal  pellagra  is  not  thoroughh-  understood. 


ACTINOMYCOSIS    (BIC.    JA\v\    OIARKHKA    IN  lOI 

but  it  is  known  that  the  changes  horc  are  \-arial>K'  anil  that  usuall\- 
the  bowel  is  thin,  relaxed,  and  atrophied,  if  not  pigmented. 

In  acute  cases  complicated  by  enteritis,  colonic  ulcers  ma>-  form 
when  the  mucosa  is  congested  and  not  anemic,  or  under  other  cir- 
cumstances. Lesions  have  also  been  encoimterod  in  the  duodenum, 
jejunum,  and  iletini,  but  the  mouth  and  rectum  are  the  parts  of  the 
gastro-intestinal  tract  most  frequently  involved  by  pellagrous  inflam- 
mation. I'nder  such  circumstances,  according  to  Roberts.^  the  anus 
is  often  swollen,  discolored,  and  fissures  and  hemorrhoids  are  occa- 
sionally present. 

Treatment. — Pellagra  is  not  aKva>s  curable,  but  a  great  deal  can 
be  done  to  reliex  e  anil  cure  the  disease  when  the  patient  follows  in- 
structions; though  it  tends  to  recur.  Sonietintes  ctirativc  agents 
should  be  discarded  for  symptomatic  remedies. 

Arsenic  preparations.  Fowler's  solution,  nie  v  to  xx  (0.30-1.30), 
three  times  daily,  often  aid,  or  soamin.  gr.  ij  to  v  (o.i2-o.3o\  hypo- 
dermically,  are  xaluable  adjinicts  to  the  treatmeitt,  and  saUarsan  has 
also  pro\'ed  helpful. 

When  the  patient  is  weak,  stipporti\"e  remedies  are  indicated,  and 
the  diet  should  be  as  generous  as  the  subject's  condition  will  permit. 
Rest  in  bed  is  unnecessary,  particularly  beticeen  attacks,  but  precautions 
should  be  taken  to  see  that  the  patient  does  not  liecome  fatigued. 

Treatment  of  the  diarrhea  requires  special  consideration,  and  the 
plan  followed  by  Roberts  appears  to  meet  the  requirements  of  the 
ordinary-  case,  \iz.:  "The  iliarrhea  is  to  a  degree  dependent  on  the 
decrease  in  the  hydrochloric  acid,  pepsin,  and  rennin  of  gastric  juice. 
During  the  height  of  the  attack,  howexer.  when  the  diarrhea  is  apt 
to  be  worse,  the  stomatitis  and  the  esophagitis  make  the  mouth  and 
esophagus  so  sensiti\'e  that  the  acid  can  be  given  only  in  small  quan- 
tities, if  at  all.  At  this  time  a  prescription  containing  tincture  of 
nux  vomica,  bismuth,  and  the  elixir  iA  lactated  j)epsin  is  freqtienily 
of  ser\'ice.  This  ma\"  be  ptit  in  the  form  oi  an  emulsion.  Later, 
another  prescription,  containing  diltite  h\drochloric  acid.  ma\-  be 
given  when  the  condition  of  the  mouth  and  throat  permits.  The 
administration  of  these  artificial  digestants  not  onl\  tends  to  lessen 
the  diarrhea,  but  also  aids  digestion,  favors  absorption,  increases  the 
stimulation,  and  promotes  the  metabolic  activit\ ,  with  a  gain  in 
weight.  When  the  diarrhea  is  \er\-  bad,  and  drains  the  patient  to 
a  serious  degree,  one  should  not  hesitate  to  administer  opium.  Bet- 
ter a  few  hypodermics  of  morphin  and  rest  than  no  rest  and  the  loss 
of  many  pounds.  Instead  of  morphin.  an  occasional  dose  of  paregoric, 
codein.  or  even  the  deodorized  tincture  may  be  given.  On  the  days 
when  the  diarrhea  is  bad  the  patient  should  be  quiet,  but  not  neces- 
sarily remain  in  bed.  and  the  diet  should  be  either  liquid  or  ver>-  light." 

Actinomycosis  iBig  Jaw\  Diarrhea  in. — This  affection  is  caused 
by  the  ra\"  fungtis  Streptothrix  actinomyces.  Actinomycosis  is  less 
common  in  the  L'nited  States  and  Britain  than  in  Germany,  and  the 

^  Pellagra,  1912. 


I02  MISCELLANEOUS    INFECTIOUS    DISEASES.    DIARRHEA    IN 

infecting  agent  is  probably  taken  in  with  the  food,  since  "big  jaw" 
frequently  attacks  cattle  and  hogs,  and  it  has  been  encountered  in 
persons  who  consumed  raw  wheat  and  n,e. 

Abdominal  actinomycosis  originates  in  the  intestines,  and  is  not 
confined  to  any  segment  of  the  bowel,  though  the  cecum  and  appendix 
are  most  frequently  involved.  The  disease  rarely,  if  ever,  attacks 
children,  and  in  the  beginning  often  causes  symptoms  similar  to  those 
of  perityphilitis. 

The  fungus  may  produce  superficial  deposits  upon  or  penetrate 
the  mucosa  (on  its  way  to  other  parts  of  the  body)  and  cause  more  or 
less  infiltration  of  the  intestinal  tunics. 

Perityphlitis  actinomycotica  is  fairly  common,  and  may  be  char- 
acterized by  the  manifestations  of  a  local  inflammation,  tumor  forma- 
tion, or  abscess  and  fistula.  Cases  of  anorectal  (secondar\-)  actino- 
mycotica have  been  reported  where  the  lesions  were  low  down  or  high 
up  in  the  rectum,  and  caused  firm,  infiltrated  masses  or  abscess  and 
fistula,  and  stricture  is  a  frequent  sequel  of  the  disease  here. 

Symptoms. — Diarrhea  is  a  common  manifestation  of  primary  and 
secondary  intestinal  actinomycosis,  and  may  be  induced  by  a  local- 
ized inflammation  (catarrh)  in  the  colon  or  an  obstruction  (from  a 
tumor  formation,  adhesion,  or  kink),  which  retains  solid  and  permits 
the  fluid  feces  to  escape.  In  most  cases  the  stomach  is  slightly  dis- 
turbed, and  diarrhea  is  irregular,  with  recurring  attacks,  and  occasion- 
ally the  actinomyces  can  be  detected  in  the  stools.  Secondary-  growths, 
abscess,  and  fistula  may  form  in  other  organs. 

Diagnosis. — The  disease  in  the  cecum,  colon,  and  rectum  should 
be  suspected  when  a  large  painless,  hard  tumor  is  present  which 
cannot  be  explained  in  other  ways,  particularly  when  it  is  connected 
with  involvement  of  the  abdominal  wall  or  a  fistula.  With  such  a 
condition  a  diagnosis  is  made  positive  by  finding  actinomyces  in  the 
discharge  or  feces. 

The  prognosis  of  actinomycosis  is  often  grave  because  of  the  ex- 
tensive inroads  made  by  the  fungus  and  the  tendency  toward  second- 
ar\-  infection  of  other  segments  of  the  bowel  or  organs.  Thus  far  only 
about  20  per  cent,  of  the  cases  of  intestinal  actinomycotica  have  been 
cured. 

Treatment. — Potassium  iodid.  tuberculin,  and  the  intravenous 
injection  of  silver  preparations  have  been  tried  with  unsatisfactory 
results.  Actinomycosis  is  a  surgical  disease,  and  a  cure  is  not  to  be 
expected  except  in  cases  where  all  diseased  foci  are  destroyed  or 
removed.  Sometimes  removal  of  the  mass  is  ad\isable.  and  at  other 
times  a  number  of  small  incisions  is  preferable,  through  which  the 
fungus  escapes. 


CHAPTER   VIII 
SUNDRY   DISEASES,   DIARRHEA   IN 

COPROSTASIS.  OBESITY,  CACHEXIA,  ANEMIA,  PERNICIOUS  ANEMIA, 
LEUKEMIA,  ALCOHOLISM,  MARASMUS,  ARTERIOSCLEROSIS. 
ENTERITIS  CROUPOSA  NECROTICA.  GOUT,  METHEMOGLOBIN- 
EMIA,  SCURVY,   CEREBROSPINAL   MENINGITIS 

Coprostasis,  Diarrhea  in. — Stercoral  or  coprostatic  diarrhea  is  usu- 
ally an  acute  process.  It  occurs  in  individuals  who  are  accustomed  to 
normal  bowel  moxements,  but  who  suddenly  become  markedh'  costive, 
those  who  suffer  from  chronic  constipation  and  recurring  impaction, 
and  may  complicate  either  atonic,  spastic,  or  mechanic  constipation 
(obstipation).  Chronic  stercoral  diarrhea  usually  complicates  obsti- 
pation Avhere  there  is  an  obstructing  intestinal  lesion — stricture, 
angulation,  adhesion,  diverticulum,  pericolitis,  external  pressure, 
foreign  body,  twist,  ptosis,  chronic  invagination,  or  tumor  that  par- 
tially blocks  the  bowel  and  causes  slight  or  complete  fecal  retention. 
Occasionally  it  is  encountered  in  functional  or  organic  diseases  which 
diminish  the  gastric  or  intestinal  secretions,  and  where  the  intestine 
is  inflamed,  hypersensitive,  or  ulcerated,  causing  enterospasm  or  the 
simultaneous  contraction  of  the  circular  and  longitudinal  intestinal 
muscular  fibers  (occlusion),  or  the  bowel  is  partially  or  completely 
paralyzed  as  the  result  of  a  cord  or  brain  lesion. 

The  loose  movements  here  are  induced  by  (a)  direct  trauma  to  the 
mucosa  by  large  putty-like  fecal  masses  or  numerous  hard,  irregular, 
nodular  scybalae  which  collect  in  considerable  numbers  and  distend 
the  bowel;  {h)  local  irritation  and  auto-intoxication  incident  to  the 
retention,  multiplication,  and  absorption  of  the  intestinal  bacteria 
or  their  toxins;  (c)  stercoral  ulcers  which  expose  the  nerve-endings  to 
the  intestinal  stimuli,  which  lead  to  abnormal  peristalsis;  {d)  the  effect 
of  psychic  impulses  upon  the  bowel  brought  about  by  worry;  {e)  the 
formation  of  irritating  gases  (marsh.  CH4;  hydrogen  sulphid,  H2S) ; 
and  (/)  cathartics  prescribed  to  soften  the  exacuations  and  prevent 
obstruction. 

The  author'  has  elsewhere  reported  45  cases  of  coprostasis,  in  the 
majority  of  which  diarrhea  was  a  complication.  A  summary  of  these 
cases  has  been  gi\en  below,  viz. : 

Sex  and  Age. — Of  the  45  cases,  22  were  men  and  23  were  women. 
Their  ages  ranged  from  eighteen  months  to  seventy-six  years.  Twenty- 
six  were  thirty-five  years  or  more,  while  19  were  under  that  age. 

^  Gant,  Diseases  of  the  Rectum  and  Anus,  1903. 

103 


I04  SUNDRY    DISEASES,    DIARRHEA    IN 

Location. — The  impaction  was  located  in  the  rectum  30  times; 
sigmoid  and  rectum,  5;  sigmoid,  6;  colon,  sigmoid,  and  rectum,  i; 
descending  colon,  i;  cecum,  i;  transverse  colon,  i. 

Weight. — The  fecal  accumulations  ranged  in  weight  from  4  ounces 
in  a  child  to  12  pounds  in  an  adult.  The  length  of  time  these  patients 
went  without  stool  varied  from  two  days  to  three  months. 

The  causes  of  impaction  directly  and  indirectly  were  as  follows: 

Stricture,  4;  carcinoma,  4;  pregnancy,  i;  careless  habits,  5;  con- 
genital malformation  of  the  anus,  i ;  traumatic  stricture,  i ;  paresis,  2 ; 
parched  corn,  2;  fruit-  and  berry-stones,  2;  adhesions,  2;  fibrous 
bands  in  rectum,  I ;  chronic  constipation,  2;  fissure,  2;  loss  of  intestinal 
tonicity,  5;  retroverted  uterus,  i;  unknown,  i;  inability  to  evacuate 
the  bowel  after  hemorrhoidal  operation,  i ;  hypertrophied  sphincter, 
i;  gall-stones,  i;  sarcoma,  i;  hypertrophied  "rectal  valve,"  i ;  green 
corn  with  portion  of  cob,  i ;  hypertrophied  levator  ani  muscle,  i ;  dis- 
seminated polypi,  i;  enterolith,  i. 

The  author  has  recorded  these  cases  with  a  view  of  pointing  out 
the  frequency  of  impaction,  or  coprostasis ;  the  necessity  of  its  prompt 
surgical  treatment;  and,  further,  to  show  the  varied  affections  and 
conditions  which  may  induce  it. 

The  symptoms  of  stercoral  or  coprostatic  diarrhea  depend  upon 
the  nature  of  the  trouble  behind  the  constipation  or  obstruction,  the 
number,  location,  and  size  of  the  impacted  masses,  and  the  duration 
and  degree  of  obstruction  caused  by  them. 

In  acute  coprostasis  the  movements  are  not  very  frequent  or 
exhausting,  but  the  patient  complains  of  gas  distention,  peristaltic 
activity,  gurgling  sounds,  and  cramps.  Relief  quickly  follows  the 
evacuation  of  scybala?  or  putty-like  masses,  semisolid  and  fluid  feces, 
and  pent-up  foul  gases  (CH4H2S),  bacteria,  toxins,  and  putrefying 
material. 

In  persons  long  afflicted  with  constipation  or  obstipation,  where 
the  bowel  never  completely  empties  itself,  and  there  is  chronic  copro- 
static or  stercoral  diarrhea,  the  symptom-complex  differs  and  the  addi- 
tional following  manifestations  may  at  one  time  or  another  be  ob- 
served: The  evacuations  continue  abnormally  frequent  week  after 
week,  varying  from  four  to  ten  daily,  have  a  vile  odor,  are  soft 
or  fluid,  contain  mucus,  pus,  blood,  and  diminutive  scybalae,  and 
induce  considerable  tenesmus  and  pain  when  evacuated,  and  the 
patient  complains  now  and  then  of  colicky  pains,  tympanites,  and 
localized  abdominal  tenderness  on  pressure  due  to  distention  of 
the  bowel,  the  ulcers,  and  a  circumscribed  peritonitis  common  in  this 
condition. 

There  are  nearly  always  manifestations  of  profound  intestinal  auto- 
intoxication, viz.:  restlessness,  melancholia,  muddy  complexion, 
offensive  breath,  indigestion,  loss  of  appetite,  dizziness,  night-sweats, 
albuminuria,  nausea,  vomiting,  etc. 

When  impaction  is  in  the  rectum  the  movements  are  very  frequent, 
the   patient  suffers  from  sensations  of    fulness,   bearing-down   pain. 


COPROSTASIS,    DIARRHEA    IN  IO5 

incessant  desire  to  evacuate  the  bowel,  tenesmus,  and  sacrococcygeal 
discomfort. 

The  diagnosis  of  stercoral  diarrhea  is  comparati\-ely  easy  when  a 
history  has  been  taken;  the  above  characteristic  manifestations  are 
exhibited  and  large  hard,  smooth,  or  nodular  masses  can  be  located 
along  the  colon,  sigmoid,  or  rectum  \)\  palpation,  instrumental  or 
digital  examination.  Fecal  tumors  causing  stercoral  diarrhea  are 
often  confused  with  carcinomata  and  other  neoplasms,  but  this  is 
unnecessary,  since  fecal  masses  are  indentable,  movable,  and  the 
bowel  can  be  made  to  slide  over  them  in  contradistinction  to  growths, 
and  there  is  no  cachexia  or  loss  of  weight. 

DrFFEREXTIAL  DIAGNOSIS    BETWEEN    FeCAL   IMPACTION    ANT)   CARCINOMA   OF   THE   LaRGE 

Intestine  and  Rectcm 
fecal  tumors  (impaction").  carcinoma. 

1.  Single,  large,  firm,  and  globular  in  shape;      Two  ox  more  dense,  rounded  tumors. 

or  numerous,  small,  hard,  and  nod- 
ular. 

2.  Not  covered  by  mucous  membrane.  Covered  by  mucosa  except  when   ulcer- 

ated. 

3.  Occupy  lumen  of  the  bowel.  Project  into  the  caliber  of  the  intestine. 

4.  Of  doughy  consistence  and  indentable.  Hard  and  non-indentable. 

5.  Not  attached.  .\ttached. 

6.  Movable.  Xon-movable  or  slightly  so. 

7.  Occur  at  any  age.  In  middle  life  and  old  age. 

8.  Xo  cache.xia.  Cachexia. 

9.  Usually  odorless.  Offensive  odor. 

10.  Come  on  suddenly.  Slowly. 

11.  No  pre\nous  histor\'  of  pain  or  hemor-      Pain  always,  hemorrhages  frequently. 

rhages. 

12.  Not  accompanied  b\- discharge  of  mucus       Free  discharge  of  mucus  and  sometimes 

or  jelly-like  stools.  of  jelly-like  ev'acuations. 

The  prognosis  of  stercoral  diarrhea  complicating  atonic  and  spastic 
constipation  is  good,  but  when  consequent  upon  chronic  intestinal 
obstruction  it  will  continue  or  occur  periodically  until  the  block  is 
corrected  b\-  physical  or  surgical  measures. 

The  treatment  of  coprostatic  or  stercoral  diarrhea  is  simple  and 
devoid  of  danger  when  it  arises  through  carelessness  in  attending  to 
the  calls  of  nature,  or  the  bowel  has  been  tied  up  by  medication, 
but  in  cases  where  fecal  retention  and  diarrhea  result  from  obsti- 
pation induced  by  a  mechanic  obstruction,  much  ingenuity  is  re- 
quired to  keep  the  bowel  free  and  control  the  diarrhea.  In  aggra- 
vated cases,  where  masses  and  scybala  cannot  be  entirely  evacuated 
or  quickly  recur,  an  operation,  such  as  intestinal  exclusion,  enteros- 
tomy, colostomy,  cecostomy,  appendicostomy ,  or  resection,  is  usually 
imperative,  but  surgical  intervention  should  not  be  resorted  to  until 
less  radical  measures  have  failed  to  relieve  the  patient. 

In  the  presence  of  an  obstruction,  sweet,  cotton-seed,  mineral  or 
castor  oil,  or  liquid  paraffin  should  be  prescribed  daily  or  periodically 
to  soften  and  cause  the  retained  fecal  accumulations  to  be  evacuated, 
but  cathartics  are  contra-indicated  in  these  cases  because  they  incite 
cramps,   active   peristalsis,   and    the   transudation   of   fluid   into   the 


I06  SUNDRY    DISEASES,    DIARRHEA    IN 

bowel  above  the  block,  which  adds  to  the  patient's  discomfort  and 
does  nothing  toward  getting  rid  of  the  fecal  mass.  In  the  absence  of 
local  pain  and  tenderness,  careful  massage  may  be  employed  to  break 
up  and  dislodge  the  tumor,  but  when  manipulation  causes  pain  it 
indicates  the  presence  of  ulcers  or  peritonitis  and  should  be  discon- 
tinued. 

Fecal  masses  responsible  for  stercoral  diarrhea  are  located  in  the 
colon,  sigmoid  flexure,  or  rectum,  and  are  amenable  to  treatment 
through  the  anus.  When  above  the  sigmoid  flexure  they  can  be  elim- 
inated by  the  administration  of  oil  employed  in  conjunction  with 
frequent  colonic  irrigation  or  high  enemata.  The  most  satisfactory 
media  to  employ  for  this  purpose  are  soapsuds,  slippery-elm  water, 
and  flaxseed  tea  because  of  their  emollient  and  lubricating  qualities. 
Two  or  three  quarts  (liters)  are  introduced  and  permitted  to  remain  in 
the  bowel  as  long  as  they  can  be  retained,  and  the  treatments  should 
be  repeated  several  times  daily  until  relief  is  obtained.  When  the  im- 
pactions become  hard,  are  coated  with  mucus,  and  water  will  neither 
permeate  nor  dislodge  them,  large  oil  enemata,  Oj  to  ij  (500—1000),  and 
turpentine,  oj  (4.0),  should  be  administered  every  five  or  six  hours 
until  the  bowel  is  cleared.  When  soapsuds  and  oil  enemata  fail,  a 
25  per  cent,  solution  of  hydrogen  peroxid,  Oij  (1000),  should  be  in- 
jected into  the  colon,  for  it  will  disintegrate  the  mass  into  smaller 
parts  so  that  it  can  be  washed  out.  Fecal  impactions  located  in  the 
sigmoid  flexure  and  rectum  can  be  broken  up  with  the  finger  or  gouge 
through  the  sigmoidoscope,  and  then  evacuated  by  continuous  soap- 
suds irrigation.  After  correcting  the  predisposing  cause,  dislodging 
and  removing  the  offending  feces,  the  bowel  should  be  treated  with 
antiseptic  and  soothing  remedies  internally  and  locally  to  heal  the 
ulcers  and  soothe  the  inflamed  mucosa. 

Obesity,  Diarrhea  in. — A  considerable  number  of  obese  indi- 
viduals are  gourmands,  eat  frequently  and  at  irregular  hours,  partake 
freely  of  highly  seasoned  foods,  and  not  infrequently  imbibe  alco- 
holic stimulants  to  excess,  with  the  result  that  they  take  on  still  more 
fat,  overtax  the  gastro-intestinal  tract,  impair  the  circulation,  cause 
engorgement  of  the  liver,  and  in  many  other  ways  disturb  the  body 
equilibrium.  The  writer  has  treated  a  number  of  fat  persons  who 
in  this  way  have  developed  an  irritable  form  of  gastro-intestinal  ca- 
tarrh, and  who  still  continued  to  gratify  their  appetite  at  the  ex- 
pense of  their  physical  comfort,  with  the  result  that  after  partaking 
of  large  amounts  of  food,  often  in  connection  with  several  glasses  of 
ice-water,  they  suffered  from  pain  and  cramps  in  the  lower  abdomen, 
followed  by  two  or  three  watery  movements  and  the  expulsion  of  con- 
siderable off^ensive  gas.  Relief  usually  followed  such  movements,  and 
comparative  comfort  prevailed  until  their  next  overindulgence.  In 
some  instances  dietetic  indiscretions  induced  a  chronic  gastro-intes- 
tinal catarrh  and  loose  movements,  \aried  from  two  or  three  to 
eight  or  ten  watery  evacuations  daily  containing  considerable  mucus, 
from  which  time  there  was  often  a  gradual  improvement,  owing  to 


OBESITY,    DIARRHEA    IN  I07 

the  fact  that  less  food  was  consumed,  either  because  the  patient  lost 
his  appetite  or  became  frightened,  ate  less,  and  restricted  himself  to  a 
more  select  diet. 

Very  severe  diarrhea  may  also  occur  in  the  obese  as  the  result 
of  constipation  and  the  accumulation  of  feces,  which,  when  retained, 
form  hard  scybalous  masses  and  excite  frequent  movements  through 
their  local  action  upon  the  gut  or  the  formation  of  stercoral  ulcers 
and  consequent  reflexes;  but,  of  all  the  diarrheas  encountered  in 
very  fat  persons,  the  most  intractable  is  that  induced  l)y  fatty  de- 
generation of  the  liver,  to  which  particular  attention  has  been  called 
by  Kisch. 

Treatment. — Whether  or  not  much  is  accomplished  in  the  treat- 
ment of  diarrhea  in  the  obese  individual  depends  principally  upon 
his  temperament  and  will  power,  because  little  or  nothing  can  be 
done  to  better  his  condition  if  he  pursues  his  usual  faulty  method  of 
living;  but  much  progress  can  be  made  toward  relieving  and  curing 
the  diarrhea  and  correcting  other  manifestations  consequent  upon 
the  fat  accumulation  if  he  will  place  himself  in  the  hands  of  one  who 
understands  his  condition,  and  will  rigidly  follow  instructions  as 
long  as  may  be  required  to  reduce  his  weight  and  stop  the  diarrhea. 

There  is  a  wide  variation  in  the  diet  lists  which  have  been  sub- 
mitted by  the  different  authorities  for  preventing  the  formation — 
and  getting  rid — of  surplus  fat,  as  will  be  seen  by  study  of  the  itinerary 
arranged  by  Banting,  Ebstein,  Oertel,  and  others. 

Briefly  stated,  the  best  results  are  obtained  by  having  these 
patients  eat  at  regular  hours,  consume  less  food  and  water,  abstain 
largely  from  alcoholic  beverages,  condiments,  and  appetizers,  exercise 
in  the  open  air,  and  refrain  from  eating  sweets,  farinaceous  foods,  fats, 
and  fluids,  except  in  very  limited  quantities. 

Thus  far  no  medical  agent  has  been  discovered  which  is  harmless 
yet  useful  in  this  class  of  cases.  The  thyroid  extract  (desiccated), 
gr.  j  (0.06),  three  times  daily,  or  thyroid  (active  principle)  has  been 
satisfactorily  employed  to  reduce  weight  rapidly,  but  should  be  dis- 
carded or  limited  as  soon  as  symptoms  of  thyroidism  appear. 

When  diarrhea  is  consequent  upon  gastro-enterocolitis  this  can  be 
controlled  by  regulating  the  diet,  flushing  the  bowel  (with  mild  saline 
antiseptic  and  astringent  solutions),  and  administering  opiates, 
antiseptics,  and  astringents  alone  or  in  combination  to  diminish  the 
number  of  stools. 

Increased  evacuations,  which  result  from  the  accumulation  of 
toxins  or  fecal  impactions  (stercoral  diarrhea),  are  most  quickly  con- 
trolled by  high  colonic  irrigations  of  water,  saline,  soap,  or  medicated 
solutions. 

After  all,  most  is  accomplished  by  ha\"ing  the  patient  take  care  of 
himself,  eat  a  reasonal)le  amount,  and  at  the  same  time  partake  of 
foods  which  are  suitable  and  agree  with  him. 

Leven  observed  several  patients  having  chronic  diarrhea  whose 
weight   increased   in   spite  of    the   loose   movements,    and    in   whom 


I08  SUNDRY    DISEASES,    DIARRHEA    IN 

cessation  of  the  diarrhea,  through  suitable  treatment,  was  followed 
by  a  diminution  in  the  weight.  These  apparently  paradoxic  obser- 
vations are  explained  by  the  author  as  due  to  the  existence  of  a 
nen'ous  regulating  apparatus  for  the  weight  of  the  body,  the  mechan- 
ism of  which  may  be  disturbed  by  a  pathologic  process  of  any  kind. 
He  points  out  the  necessity  for  a  gradual  emaciation  of  the  obese,  as 
a  rapid  loss  of  flesh  depends  rather  upon  a  dangerous  loss  of  water 
instead  of  upon  a  loss  of  fat. 

Cachexia,  Diarrhea  in. — Diarrhea  is  often  associated  with  ca- 
chexia, but  the  frequent  movements  should  be  considered  as  a  mani- 
festation of  cancer,  tuberculosis,  pus  accumulations,  kidney  lesions, 
or  other  serious  afifection  where  cachexia  is  a  symptom. 

Consequently,  the  treatment  of  diarrhea  in  cachexia  should  con- 
sist in  relieving  or  correcting  the  pathologic  condition  responsible  for 
it.  along  with  measures  directed  against  the  intestine  when  there  are 
local  lesions  which  are  in  part  responsible  for  the  frequent  evacua- 
tions. 

Anemia,  Diarrhea  in. — Frequent  evacuations  in  anemic  subjects 
are  encountered  less  often  than  obstipation,  and  when  present  the 
intestinal  mucosa  is  ver\-  sensitive,  and  there  is  an  acute  or  chronic 
catarrhal  inflammation  of  the  bowel  which  is  responsible  for  the 
increased  evacuations  and  mucus.  In  this  condition  the  anemia  may 
be  the  result  of  general  causes  or  local  lesions  of  the  intestine,  accom- 
panied by  a  few  severe  or  many  slight  recurrent  hemorrhages.  In  the 
latter  case  it  is  more  than  likely  that  the  erosions  or  ulcers  are  the 
exciting  cause  of  the  diarrhea. 

In  pernicious  anemia  there  may  be  constipation  at  one  time  or 
diarrhea  at  another,  and  while  the  latter  prevails  there  is  usually 
more  or  less  gastric  irritation. 

Hertz  claims  that  the  peculiarities  of  this  type  of  diarrhea  con- 
sist in  yellowish-green  evacuations  resembling  those  of  typhoid 
fever  (at  most  six  times  daily),  which  are  not  quite  waterv^  and  rarely 
contain  blood.  The  evacuations  are  independent  of  dyspeptic  dis- 
turbances and  are  sometimes  seen  in  the  early — but  usually  occur  in 
the  later — stages  of  the  disease. 

Pernicious  anemia  may  also  be  confused  with  ordinan.-  anemia 
consequent  upon  intestinal  hemorrhages  from  the  ulcerative  t\'pes 
of  colitis,  but  can  ordinarily  be  difterentiated  from  it  by  getting  a 
histon.-  of  the  case,  inspecting  the  bowel  through  the  sigmoidoscope, 
and  by  examining  the  blood  and  stools. 

Treatment. — When  the  mucosa  is  intact  and  the  gastro-intestinal 
disturbances  are  only  a  part  of  the  general  anemic  process,  sup- 
portive measures,  such  as  fresh  air.  nutritive  food,  regular  hours, 
moderate  exercise,  and.  if  necessary-,  change  of  occupation  or  sur- 
roundings, are  indicated  in  combination  with  iron,  arsenic,  strychnin, 
quinin,  and  other  medicines  which  improve  the  condition  of  the 
blood,  tone  up  the  ner\^ous  system,  and  increase  the  bodily  strength. 
When   anemia  or  chlorosis  is  the  result  of  intestinal  lesions  which 


LEUKEMIA,    DIARRHEA    IN  IO9 

bleed  freely,  the  above  plan  of  treatment  is  still  indicated,  but,  in 
addition  to  this,  liberal  doses  of  bismuth  subnitrate  and  salicylate, 
beta-naphthol,  salol,  guaiacol,  tannin,  tanniform,  tannalbin,  ichtho- 
form,  or  other  antiseptic  and  astringent  remedies  should  be  pre- 
scribed because  they  favor  healing  and  lessen  the  formation  of  intes- 
tinal toxins. 

Beneficial  results  are  nearly  always  attainable  in  tiiis  class  of  cases 
by  daily  flushing  the  bowel  from  above  through  an  appendiceal  or 
cecal  opening,  or  from  below  through  the  anus,  with  either  normal 
saline,  boric  acid  (2  per  cent.),  ichthyol  (2  per  cent.),  permanganate 
of  potassium  (i  per  cent.),  or  tannic  acid  (i  per  cent.)  solutions,  care 
being  taken  to  see  that  the  fluid  reaches  all  parts  of  the  colon. 

When  ulcers  are  within  reach  of  the  sigmoidoscope,  they  can 
be  made  to  heal  more  rapidly  by  topical  applications  of  silver  nitrate, 
6  per  cent.;  ichthyol,  20  per  cent.;  balsam  of  Peru,  20  per  cent.,  or, 
when  unhealthy,  by  stimulating  them  with  full  strength  silver  nitrate 
or  copper  sulphate. 

The  author  has  obtained  some  remarkable  results  with  through- 
and-through  irrigation  in  the  treatment  of  chlorosis,  ordinary  and 
pernicious  anemia  following  ordinary  cecostomy  (see  Fig.  95),  appendi- 
costomy  (see  Fig.  148),  and  his  cecostomy,  which  provides  a  means  of 
irrigating  both  the  small  and  large  intestine  at  the  same  time  (see 
Fig.  143),  and  employment  of  the  above-mentioned  or  other  irrigating 
solutions.  The  results  demonstrate  clearly  that  auto-intoxication  is 
an  important  factor  in  the  production  of  the  anemic  condition,  or  that 
there  is  some  other  close  pathologic  relation  between  the  bowel  and 
these  ailments. 

Improvement  has  been  oijserved  in  these  cases  where  irrigation 
was  restricted  to  the  colon,  but  still  better  results  have  been  obtained 
when  the  author's  method  of  frequently  irrigating  both  the  small  and 
large  intestine  was  practised.  His  enterocolonic  irrigator  (see  Fig.  142) 
enables  the  attendant  to  wash  out  either  the  small  intestine  or  colon, 
or  both,  at  will,  and  also  to  cause  the  medicated  solution  to  be  retained 
as  long  as  may  be  desired,  wliich  in  some  instances  is  a  great  advantage. 

Pernicious  Anemia,  Diarrhea  in. — Gastralgia,  abdominal  pain, 
and  diarrhea  are  frequent  complications  of  pernicious  anemia,  and 
pyorrhea  and  an  eroded  tongue  are  often  in  evidence.  The  diarrhea 
in  such  cases  can  be  attributed  in  part  to  the  hypochlorh\clria  or 
achylia  gastrica  that  prevails. 

Diarrhea  from  this  source  is  best  controlled  by  opiates  during 
crises  and  rest  in  Ijed,  fresh  air,  nourishing  food,  and  Fowler's  solu- 
tion, Tipjij  to  v  (0.20-0.30)  or  more,  three  times  dail\-.  In  addition, 
other  remedies  known  to  improve  the  condition  should  he  prescribed. 
The  author  has  obtained  remarkably  good  results  in  this  class  of  cases 
from  frequent  medicated  colonic  irrigations. 

Leukemia,  Diarrhea  in.  In  this  affection  the  bowel,  like  other 
organs,  Irecjuently  becomes  i)rimarily  or  secondarily  inxohed  (Fig.  25, 
Hillman),  and  the  patient  may  suft'er  from  costiveness,  diarrhea  alone, 


no 


SUNDRY    DISEASES,    DIARRHEA    IN 


or  alternateh".  The  e\acuations  when  abnormally  frequent  are  usu- 
ally light  colored  and  pasty,  but  when  they  contain  a  considerable 
amount  of  bile-pigment  or  blood  they  are  brownish  or  even  black, 
but  in  those  cases  where  diarrhea  results  from  enterocolitis  the  stools 
are  more  normal  in  color,  contain  mucus,  and  occasionally  pus  and 
blood.     Frequently    gas    forms    and    causes    meteorism,    abdominal 

pain,  and  a  sensation  of  fulness  and 
tenesmus  may  ensue  when  it  and  the 
feces  are  expelled.  In  rare  instances 
ulcers  of  considerable  size  have  been 
observed,  and  enlarged  lymph-nodes 
have  been  found  which  were  inflamed 
or  necrosed. 

In  pseudoleukemia  (Hodgkin's  dis- 
ease) diarrhea  is  seldom  an  early — but 
is  frequently  a  late — complication  in 
severe  cases,  and  is  ven,-  difificult  to 
control  throughout.  The  stools  con- 
tain mucus,  and  occasionally  mild  or 
severe  bleeding  from  hemorrhoids  or 
lesions  higher  up  takes  place,  and  the 
glands  adjacent  to  the  intestine  be- 
come markedly  enlarged,  but  seldom 
cause  intestinal  manifestations. 

The  treatment  of  leukemia  and 
pseudoleukemia  is  extremely  unsatis- 
factory, though  some  authorities  claim 
that  much  benefit  can  be  obtained  by 
exposing  the  enlarged  glands  to  the 
Rontgen  rays.  Chief  reliance,  how- 
ever, should  be  placed  upon  the  sup- 
portive and  symptomatic  treatment 
of  the  patient. 

Iron  and   arsenic,   in    conjunction 
with    intestinal    antiseptics,  are    ser- 
viceable in  controlling  diarrhea,  but 
when  these  agents  fail,  an  opiate  should  be  given.     In  case  there  are 
lesions  in  the  colon,  irrigations  and  topical  applications  are  indicated. 
Surgery  has  been  resorted  to  in  this  class  of  cases,  but  the  results 
hax'c  been  disappointing. 

Alcoholism,  Diarrhea  in. — Individuals  who  consume  in  a  few 
hours  large  amounts  of  whisky,  brandy,  gin,  and  other  beverages 
containing  from  30  to  60  per  cent,  or  more  of  alcohol,  or  who  regu- 
larly partake  of  alcohol  in  liberal  amounts,  are  apt  to  develop  an  acute 
or  chronic  catarrhal  gastro-enteritis  and  diarrhea. 

In  acute  alcoholism  the  disturbance  is  of  short  duration,  and  the 
patient  complains  of  nausea,  vomiting,  loss  of  muscular  control,  in- 
coordination  of   speech,    stertorous   breathing,    occasionally    inconti- 


Fig.  25. — LjTnphatic  leukemia  in- 
voh-ing  the  colon.  Note  multiple 
subcutaneous  nodules,  and  also  en- 
larged Ij-mph-nodes  of  mesocolon. 


ALCOHOLISM,    DL\RRHEA    IN  III 

nence  of  urine  and  feces,  and,  in  iiggrav'ated  cases,  delirium  tremens 
or  coma,  all  of  which  manifestations  abate  or  cease  altogether  shortly 
following  a  cessation  of  drinking. 

Chronic  alcoholism  is  now  regarded  as  a  disease  produced  by  con- 
stant saturation  of  the  body  with  alcohol,  which  in  time  profoundly 
affects  the  general  system,  stomach,  intestines,  liver,  and  other  organs, 
and  gradually  produces  the  symptom-complex:  anorexia,  obnoxious 
breath,  morning  vomiting,  gastric  discomfort  after  eating,  insomnia, 
headache,  restlessness,  depression,  dementia  and  delirium  tremens, 
impaired  metabolism,  and  constipation  alone  or  alternating  with 
diarrhea,  or  the  latter  may  prevail. 

Diarrhea  in  these  cases  results  from  the  thickened,  inflamed,  con- 
gested and  often  ulcerated  intestinal  mucosa,  imperfect  gastro-intes- 
tinal  indigestion,  interference  with  colonic  absorption,  disturbance 
of  the  biliar\'  circulation,  and  the  effect  of  alcohol  upon  the  local  and 
cerebrospinal  nerve-centers  controlling  intestinal  nutrition,  secretion. 
and  motility. 

The  treatment  of  diarrhea  in  acute  alcoholism  consists  in  withdraw- 
ing the  drug,  keeping  the  patient  in  bed  on  a  liquid  diet,  washing 
out  the  stomach  to  abate  nausea  and  vomiting,  flushing  the  bowel 
with  soothing  agents  to  relieve  irritation  and  removing  retained  feces 
and  toxins,  prescribing  remedies  that  will  relieve  headache  and 
insure  sleep  until  the  patient  has  somewhat  recovered  from  the 
effects  of  his  debauch,  and  in  taking  precautions  to  prevent  further 
drinking. 

In  chronic  alcoholism  the  above  measures  will  suffice  during  exacer- 
bations, but  permanent  results  depend  principalK"  on  the  success  met 
with  in  limiting  the  amount  of  liquor  consumed,  regulating  the  diet, 
improving  the  nervous  state,  and  in  instituting  therapeutic  measures 
to  minimize  or  cure  the  catarrhal  gastro-enterocolitis  responsible 
for  the  frequent  movements. 

The  diarrheal  condition  improves  in  favorable  cases  in  proportion 
as  the  amount  of  alcohol  consumed  is  diminished  and  congestion  of 
the  mucosa  becomes  less;  but  frequently  in  chronic  inebriates  who 
have  been  cured  there  persists  a  chronic  enterocolitis  that  requires 
further  treatment.  The  occasional  administration  of  saline  laxatives 
is  verv^  serviceable  because  they  diminish  intestinal  congestion,  free 
the  bowel  of  imperfecth'  digested  food,  and  have  a  favorable  influence 
upon  the  catarrh. 

When  enterocolitis  and  diarrhea  dominate  the  symptom-complex 
of  chronic  alcoholism,  the  bowel  deserves  first  consideration,  and 
opium,  gr.  5  (0.03),  and  the  extract  of  belladonna,  gr.  \  (0.008),  can 
be  relied  upon  to  control  the  movements,  relieve  pain  and  intestinal 
irritability,  as  can  also  morphin,  laudanum,  or  other  opiates,  alone  or 
in  combination  with  bismuth,  gr.  x  to  xx  (0.60-1.30),  tannoform,  ich- 
thalbin,  and  gallic  acid,  gr.  v  to  x  (0.30-0.60);  but  opiates  should  be 
prescribed  with  caution,  otherwise  the  patient  becomes  habituated 
to  them. 


112  SUNDRY    DISEASES,    DIARRHEA    IN 

When  fermentation  and  putrefaction  are  marked,  calomel,  salol, 
beta-naphthol,  and  reliable  antiseptics  may  be  added  to  the  treatment, 
but  when  there  is  a  tendency  to  stagnation,  gastric  and  intestinal 
lavage  is  indicated. 

The  treatment  of  alcoholic  intestinal  catarrh  should  not  be  quite 
so  vigorous  as  other  forms,  since  here  the  bowel  is  extremely  irritable 
and  often  reacts  against  injected  solutions  having  a  strong  stimulat- 
ing tendency.  On  account  of  this  peculiarity  the  writer  has  been 
accustomed  to  employ  warm  flaxseed  tea,  starch,  or  slippery-elm 
water,  and  very  mild  infusions  of  black  or  white  oak  bark,  agents 
which  soothe  the  bowel,  reduce  inflammation,  and  tend  to  heal  ero- 
sions of  the  mucosa.  In  severe  cases,  where  diarrhea  is  persistent 
and  the  stools,  because  of  the  presence  of  ulcers,  contain  considerable 
pus.  blood,  and  mucus,  stronger  irrigants,  such  as  boric  acid,  2  to  4 
per  cent.;  ichthyol,  i  to  2  per  cent.;  permanganate  of  potassium  and 
balsam  of  Peru,  i  per  cent.,  containing  laudanum,  mt  xx  (1.30).  and 
tincture  of  belladonna,  irg  x  (0.60),  are  preferable. 

With  the  patient  in  the  proper  position,  and  with  the  aid  of  the 
proctoscope,  colon  tube,  and  the  irrigating  container  at  the  right 
height,  a  fluid  can  usually  be  made  to  reach  all  parts  of  the  colon,  but 
when  this  is  not  feasible,  appendicostomy  or  cecostomy  should  be 
performed  to  insure  through-and-through  irrigation. 

Marasmus,  Diarrhea  in. — Frequent  evacuations  are  sometimes 
observed  in  chronic  marasmus,  but  diarrhea  is  encountered  in  this 
affection  more  frequently  and  severely  when  it  develops  rapidly. 
The  stools  may  resemble  those  of  simple  enterocolitis,  or  be  watery 
and  serous-like  when  transudation  into  the  intestine  is  marked.  In 
the  latter,  diarrhea  is  probably  attributable  to  disturbance  of  the 
intestinal  nervous  mechanism,  lack  of  absorption,  or  to  impairment  of 
the  local  circulatory  apparatus. 

Treatment. — Naturally,  this  type  of  loose  movements  occurs  very 
much  more  often  in  infanc\'  than  in  older  subjects,  due  largely  to 
improper  feeding  and  malnutrition.  From  what  has  been  said  it 
may  be  inferred  that  the  treatment  is  based  upon  improved  feeding, 
nerve  and  systemic  tonics,  fresh  air,  sunshine,  remedies  to  alleviate 
intestinal  catarrh,  and  local  irrigations  to  heal  an  inflamed  and,  in  ex- 
ceptional instances,  an  ulcerated  mucosa,  thereby  reducing  irritation  so 
that  the  nutrient  media  may  remain  in  the  intestine  sufficiently  long 
for  absorption  to  take  place. 

Arteriosclerosis,  Diarrhea  in. — Arteriosclerosis  of  the  mesenteric 
vessels  often  produces  manifestations  resembling  gall-stone  colic,  and 
gastro-intestinal  symptoms  varied  in  character  and  cholera-like  diar- 
rhea from  this  source  has  been  observed. 

In  such  cases  the  treatment  does  not  differ  materialK"  from  that 
indicated  in  general  arteriosclerosis. 

Enteritis  Crouposa  Necrotica,  Diarrhea  in. — This  condition  is 
characterized  by  extensive  sloughing,  and  then  ulceration  of  the 
intestine,  accompanied  by  diarrhea,  irrespective  of  the  causes  of  the 


CEREBROSPINAL    MENINGITIS,    DIARRHEA    IN  II3 

condition,  of  which  there  are  many.  In  the  majority  of  instances  the 
sloughing  and  loose  movements  are  secondary  to  nephritis  and  uremia, 
mercurial  poisoning,  bacillary,  balantidic,  and  entamebic  colitis  (dysen- 
tery), intestinal  obstruction  (complicated  by  interference  with  the 
circulation  of  the  intestinal  tunics),  final  stages  of  wasting  diseases 
(syphilis,  tuberculosis,  septicemia,  etc.),  diphtheria,  and  occasionally 
pneumonia. 

The  local  symptoms  of  this  form  of  diarrhea  are  the  same  as  for 
other  forms  of  ulcerative  colitis. 

The  diagnosis  is  easily  made  with  the  aid  of  the  sigmoidoscope 
and  fecal  examination. 

The  treatment  consists  in  keeping  the  patient  quiet,  restricting  the 
diet,  administering  opiates  and  bismuth  to  comfort  the  patient  and 
diminish  the  number  of  stools;  in  irrigating  the  colon  from  below  or 
through  an  appendiceal  or  cecal  opening  and  in  resecting  the  diseased 
gut  when  less  radical  measures  fail. 

Gout,  Diarrhea  in. — Gout  is  more  often  complicated  by  consti- 
pation than  diarrhea,  but  when  loose  movements  prevail  they  are 
usually  associated  with  flatulence,  (hspepsia.  pyrosis,  and  abdomi- 
nal pains. 

The  treatment  is  symptomatic  as  far  as  the  gastro-intestinal  mani- 
festations are  concerned,  but  the  usual  treatment  for  gout  should  be 
instituted  to  prevent  a  recurrence  of  the  diarrhea. 

Methemoglobinemia,  Diarrhea  in. — Chronic  diarrhea  has  been 
frequently  obser\ed  in  this  condition,  and  Gibson  and  Douglas  sug- 
gested the  name  microbic  cyanosis  for  the  colon  organism  obtained 
from  the  blood  of  their  patient,  and  Gartner's  bacillus  has  caused  the 
disease  in  rats. 

Scurvy  (Scorbutus),  Diarrhea  in. — Scurvy  is  common  among 
sailors  who  take  long  voyages,  but  its  etiology  is  not  known,  and  it  is 
supposed  to  be  induced  by  lack  of  fresh  vegetables,  toxic  substances 
in  the  food,  or  an  unknown  specific  organism. 

It  comes  on  insidiously  and  is  characterized  by  a  loss  in  weight, 
diseased  and  bleeding  gums,  loose  teeth,  foul  broth,  swollen  tongue, 
dry  skin,  ecchymosis,  mental  depression,  and  either  constipation  or 
diarrhea. 

Treatment. — It  can  be  cured  by  lemon-juice  daily,  together  with 
wholesome  meat  and  fresh  vegetables.  Much  can  be  added  to  the 
patient's  comfort  by  frequent  mouth-washing  with  a  weak  permangan- 
ate or  carbolic  solution. 

Cerebrospinal  Meningitis,  Diarrhea  in. — Gastro-intestinal  com- 
plications are  usually  not  annoying  in  this  affection,  but  when  iliey 
are,  diarrhea  occurs  less  often  than  constipation. 


CHAPTER    IX 
SUNDRY  DIARRHEAS 

DIARRHEAS  FROM  IRREGULARITIES  IN  LIVING,  CATHARSIS,  HYPO- 
DYNAMIA CORDIS,  BURNS,  AGORAPHOBIA,  SITOPHOBLA,  CHILL- 
ING, DRINKING  IMPURE  WATER  AND  ICE-COLD  BEVERAGES, 
SUN-  AND  HEAT-STROKES,  OLD  AGE,  NOCTURNAL,  EOSINO- 
PHILIC,  MECHANIC,  AND  REFLEX   DIARRHEAS 

Irregularities  in  Living,  Diarrhea  from.^ — Meals,  to  be  properly 
digested,  should  be  taken  at  regular  hours  and  eaten  slowly  and 
amidst  pleasant  surroundings.  It  is  not  surprising  that  individuals 
who  eat  much  more  than  they  need  at  all  times  of  the  day  or  night, 
and  highly  seasoned  or  indigestible  foods,  suffer  from  gastro-intestinal 
disturbances  and  diarrhea,  because  the  organs  are  overworked  and 
are  being  constantly  irritated,  particularly  when  the  meals  are  hurriedly 
eaten  and  the  food  is  improperly  masticated,  or  is  consumed  very  hot 
or  ice  cold. 

Digestion  is  frequently  interfered  with  because  of  the  large  amounts 
of  whisky,  beer,  tea,  coffee,  wine,  or  ice-cold  water  consumed  with 
the  food,  which  abnormally  dilute  it,  set  up  fermentation,  or  irritate 
the  mucosa. 

Indiscretions  in  diet  are  frequently  responsible  for  diarrhea, 
although  it  must  be  remembered  that  some  individuals  can  take  care 
of  certain  foods  better  than  others.  Vegetables,  like  radishes,  cab- 
bage, turnips,  celery,  parsnips,  and  onions,  which  leave  a  coarse, 
irritating  residue,  and  raw  fruits,  particularly  when  improperly 
masticated,  are  prone  to  induce  indigestion  and  diarrhea,  as  does  also 
an  over  amount  of  fat  which  may  split  up  in  the  stomach,  forming 
irritating  fatty  acids.  Beef  and  pork  are  more  difficult  for  the  digest- 
ive fluids  to  break  up  than  mutton,  and  the  latter  than  chicken  or  fish; 
consequently,  when  it  is  found  that  one  is  indigestible,  another  should 
be  substituted.  Patients  with  an  irritable  gastro-intestinal  tract 
should  be  warned  against  eating  salted  or  smoked  meat  or  fish,  and 
the  flesh  of  killed  animals  while  in  rigor  mortis,  because  they  are  always 
tough,  and  salmon  and  herring,  because  of  the  contained  oil.  Meats 
are  also  more  digestible  when  they  are  from  young  than  old  animals, 
and  boiled  instead  of  roasted,  and  the  skin  and  ligamentous  portions 
should  be  discarded,  because  the  digestive  fluids  act  upon  them  slowly 
if  at  all.  The  consumption  of  fresh  bread  often  interferes  with  diges- 
tion, while  stale  or  toasted  bread  does  not,  because  it  is  easily  broken 
up  and  digested. 

'  See  Gastrogenic  and  Enterogenic  (Lienteric)  Diarrhea. 
114 


niAKKHEA    CATHARTICA  II5 

The  symptoms  in  tliis  \.\\)c  of  diiirrhea  are  about  the  same  as  those 
accompanying  enteritis,  elsewhere  descril)ed. 

The  didi^Jiosis  is  easy  in  some  and  difficult  in  other  cases.  The 
nature  of  ihc  imuMc-,  liowever,  can  usualU-  he  determined  by  getting 
the  history  and  learning  if  the  patient  is  a  g(jurmand,  leads  an  irregu- 
lar life,  eats  indigestible  food,  and  by  making  one  or  more  examina- 
tions of  the  gastric  contents  and  feces  following  Schmidt's  test-meal. 

The  treatment  consists  princii)ally  in  ha\ing  the  patient  abstain 
from  alcohol,  establish  reiiuldr  hours  for  sleeping,  eating,  and  attend- 
ing to  the  calls  of  nature,  liniiiing  tlie  amount  of  food  consumed, 
and  restricting  it  to  articles  (A  diet  known  to  agree  with  him.  In 
most  instances,  gastric  and  intestinal  lavage  afford  considerable  relief 
by  washing  the  stomach  and  bowel  free  from  their  irritating  contents 
and  quieting  the  irritable  and  inflamed  mucosa,  particularly  when 
tnedicaments  are  added  to  the  solution.  When  diarrhea  persists  in 
spite  of  this  treatment,  an  opiate,  sedative,  antiseptic,  or  an  astrin- 
gent alone,  or  in  combination,  should  be  prescribed  and  administered 
as  often  as  may  be  necessary  to  control  the  evacuations. 

Diarrhea  Cathartica. — Diarrhea  is  frcriuenth'  a  sequel  of  chronic, 
atonic,  spastic,  and  mechanic  constipation,  and  may  result  from 
frequently  recurring  fecal  impaction,  which,  through  trauma  or  the 
effects  of  retained  toxins,  causes  a  local  inflammation,  ulceration,  or 
both,  which  may  incite  loose  movements.  Most  often,  however, 
diarrhea  is  produced  by  the  long-continued  employment  in  ever- 
increasing  dosage  of  laxatives,  cathartics,  and  purgatives,  which, 
through  their  general  action  and  local  irritation,  continually  cause 
an  abnormal  transudation  of  fluid  into  the  intestines,  glandular  activ- 
ity, and  inflammation,  with  erosions  or  ulcerations  of  the  mucosa. 

Gastric  or  enterocolonic  catarrh  thus  ensues  similar  to  that  which 
results  from  gastro-intestinal  dyspepsia  or  which  necessarily  follows 
when  unprepared  food  is  rushed  through  the  gastro-intestinal  tract, 
day  after  day,  month  after  month,  and  year  after  year  by  the  fre- 
quent and  pernicious  peristaltic  movements  incited  by  the  taking 
of  drugs  to  secure  the  coveted  daily  evacuations. 

Again,  prolonged  obnoxious  medication  in  this  way  tends  to 
weaken  the  patient  and  lower  his  resistance,  subjects  him  upon  slight 
provocation  to  catarrhal  infections  and  other  diseases,  and  eventually 
produces  an  abnormal  condition  of  the  colon  that  leads  to  ulceration 
or  prevents  absorption.  The  fluidity  of  the  movements  in  time 
cause  an  irritable  state  of  the  rectum  characterized  by  tenesmus  and 
an  inability  on  the  part  of  the  patient  to  retain  the  feces  when  they 
reach  the  lower  bowel. 

Drastic  cathartics,  such  as  colocynth,  podoph\  Hum,  jalap,  gamboge, 
elaterium,  castor  oil,  and  croton  oil,  act  by  enlivening  peristalsis. 
Hydrago'f!^ues  or  saline  cathartics,  such  as  sodium  sulphate  and  tar- 
trate, magnesium  sulphate  and  citrate,  and  potassium  l)itartrate, 
produce  large  watery  movements  through  their  liberal  withdrawal 
of  water  from  the  intestinal  walls.     Cholagogues,  like  mercur\-,  aloes, 


Il6  SUNDRY    DIARRHEAS 

and  leptandra.  both  excite  active  peristalsis  and  an  abnormal  secre- 
tion of  bile;  the  laxatives — viz.,  cascara  sagrada,  manna,  tamarind, 
sulphur.  oli\e  oil,  and  hyoscyamus — do  the  least  harm,  because  they 
but  mildly  stimulate  peristalsis  and  glandular  activity,  while  mineral 
waters  increase  the  frequency-  and  fluidity  of  the  evacuations  through 
their  saline  constituents,  thermic  and  mechanical  action,  and  by 
increasing  the  amount  of  water  in  the  bowel. 

The  treatment  of  diarrhea  cathartica  consists  in  discontinuing  the 
medical  agents  responsible  for  the  trouble,  or,  if  they  must  be  pre- 
scribed, using  them  in  smaller  amounts  and  through  agents  which 
will  produce  the  minimum  amount  of  gastro-intestinal  disturbance. 
When  urgent,  antidiarrheal  remedies  maybe  judiciously  prescribed  until 
such  time  as  the  catarrhal  condition  of  the  bowel  can  be  corrected. 

Hypodynamia  Cordis,  Diarrhea  in. — Occasionally,  elderly  patients 
complain  of  heart  fatigue  and  suffer  from  diarrhea  or  spastic  obsti- 
pation that  does  not  respond  to  cathartics.  According  to  Jaworski, 
the  majority  of  these  patients  suffer  from  latent  or  manifest  inflam- 
matory or  nutritive  changes  of  the  myocardium  (chronic  myocarditis, 
degeneration  of  the  heart  muscle,  fatty  heart,  and  arteriosclerosis). 
In  this  class  of  sufferers  the  author  has  been  accustomed  to  regard 
the  diarrhea  as  coprostatic,  consequent  upon  enterospasm.  In  these 
cases  he  discards  remedies  ordinarily  employed  to  empty  the  bowel 
(laxatives  and  cathartics)  for  heat  applied  to  the  abdomen  in  con- 
junction with  belladonna,  which  tend  to  relax  the  intestinal  muscula- 
ture and  liberate  the  accumulated  feces.  In  some  cases  dislodgment 
and  evacuation  of  the  impacted  masses  can  be  quickly  and  satisfac- 
torily obtained  through  the  administration  of  olive  or  mineral  oils 
and  by  copious  hot  soapsuds  or  oil  enemata,  agents  which  soften  the 
feces  and  lubricate  the  bowel. 

Burns,  Diarrhea  from. — One  of  the  most  remarkable  and  interest- 
ing manifestations  connected  with  very  extensive  burns  of  the  skin  is 
the  frequent  formation  of  duodenal  and,  rarely,  gastric  ulcers,  which 
sometimes  cause  perforation  and  peritonitis.  Some  authorities 
believe  this  condition  is  due  to  thrombosis  within  the  duodenal  cir- 
culation, caused  by  the  setting  free  of  fibrin  ferment,  but  this  ex- 
planation has  not  met  with  universal  approval,  although  no  better 
has  been  offered.  The  hyperemic  inflammatory'  and  ulcerated  condi- 
tion is  limited  principally  to  the  superior  horizontal  portion  of  the 
duodenum,  and  is  very  rarely  encountered  in  the  inferior  extremity 
of  this  segment  of  gut  or  further  along  the  intestinal  tract.  The 
lesions  may  be  single  or  multiple  and  conglomerated,  and  show 
various  stages  of  development  with  superficial  hemorrhagic  infarcts 
at  one  point,  or  deep  ulcers  of  considerable  size  at  another,  about 
which  the  mucosa  is  congested.  The  lesions  may  develop  rapidly 
and  attain  considerable  size  within  forty-eight  hours,  but,  as  a  rule, 
they  manifest  themselves  at  the  end  of  one  or  two  weeks,  and  are  so 
characteristic  that,  with  the  history,  there  is  no  reason  for  confusing 
them  with  other  types  of  duodenal  ulcers. 


SITOPIIORIA,    DIARRHEA    IN  IIJ 

In  fatal  cases  death  occurs  in  from  three  to  five  days,  sometimes 
from  erosion  of  and  hemorrhage  from  tlie  pancreaticoduodenal  artery, 
but  most  often  from  perforation  and  j^eritonitis.  In  more  favorable 
instances  diarrhea  may  be  a  complication  and  result  from  impair- 
ment to  the  digestive  apparatus  or  irritation  to  the  exposed  nerve- 
endings  at  the  site  of  the  lesions. 

The  treatment  of  diarrhea  complicating  extensive  burns  is  symp- 
tomatic. The  chief  thing  is  to  relieve  the  terrible  suffering  induced  by 
the  wound,  which  consists  in  protecting  it  from  the  air,  puncturing  the 
vesicles,  keeping  the  parts  submerged  in  water  or  covered  with  oil, 
applying  antiseptic,  soothing,  and  stimulating  remedies,  and  later, 
skin-grafting,  according  to  the  stage  and  character  of  the  lesion. 

Diarrhea  here  is  treated  by  restricting  the  diet,  administration  of 
opiates,  antiseptic  and  astringent  remedies,  as  in  other  types  of 
acute  enteritis,  together,  when  necessary,  with  flushing  the  bowel,  but 
when  perforation  occurs  the  usual  measures  practised  for  the  relief 
of  peritonitis  should  be  at  once  instituted,  though  operati\'e  inter- 
ference is  rarely  permissible  on  account  of  the  patient's  general  condi- 
tion. 

Agoraphobia,  Diarrhea  in. — This  form  of  loose  movements  occurs 
in  certain  individuals  when  in  large  audiences  from  the  fear  that 
they  will  have  to  go  to  the  toilet,  and  the  impulse  thus  generated 
often  excites  excessive  peristalsis  and  even  the  transudation  of  fluid 
into  the  intestine,  causing  several  fluid  evacuations  in  rapid  suc- 
cession. Patients  who  have  once  had  this  experience  have  it  con- 
stantly before  them,  and  are  almost  universally  subjected  to  similar 
attacks  while  at  receptions,  in  the  theater,  or  restaurant,  and  more 
particularly  when  they  are  in  doubt  whether  in  case  of  need  they 
can  escape  to  the  toilet.  The  author  has  known  of  cases  where  for  the 
time  being  the  patient  lost  control  of  the  movements,  they  being 
involuntarily  discharged,  and  Oppenheim  calls  attention  to  the  fact 
that  through  this  autosuggestion  sphincteric  tenesmus  ensues,  and 
then  the  intestinal  contents  are  voided. 

The  treatment  of  this  and  other  forms  of  psychic  loose  movements 
is  fully  discussed  in  the  chapter  devoted  to  Neurogenic  Diarrheas, 
and  needs  no  further  discussion  here. 

Sitophobia,  Diarrhea  in. — Patients  who  suffer  from  sitophobia, 
or  the  fear  of  eating  because  of  the  ill  effects  which  they  believe  will 
ensue,  occasionally  suffer  from  diarrhea  engendered  by  gastro-intes- 
tinal  dyspepsia.  These  sufferers  restrict  their  diet  to  such  a  degree 
that  the  intestinal  secretions  are  not  sufficiently  stimulated,  mal- 
nutrition results,  and  the  bowel  becomes  irritable  to  such  an  extent 
that  it  throws  off  the  improperly  digested  food  before  it  has  an 
opportunity  to  be  absorbed.  Once  this  type  of  loose  mo\  ements  is 
established,  the  diarrhea  is  continually  aggravated  through  psychic 
impulses  consequent  upon  worry  Ijccause  of  the  frequent  evacuations 
and  the  fear  of  them. 

The  treatment  of  sitophobic  diarrhea  is  largely  psychic,  and  con- 


Il8  SUNDRY    DIARRHEAS 

sists  in  encouraging  the  patient  to  believe  that  his  condition  is  not 
serious,  that  the  eating  of  more  food  will  not  hurt  him,  and  that  in  a 
short  time  he  will  recover,  but  the  desired  results  can  be  most 
quickly  and  effectively  accomplished  b>'  gradation  of  the  amount  of 
the  food  consumed  until  a  normal  diet  has  become  established.  In 
addition.  ver>-  neurotic  individuals  require  remedies  to  correct  this 
condition  and  enable  them  to  obtain  the  necessary-  amount  of  rest 
and  sleep. 

Chilling,  Diarrhea  from. — Increased  frequency  of  the  evacuations 
is  a  common  and  distressing  manifestation  of  "chilling"  brought  on 
through  exposure  to  cold  and  dampness,  as  when  the  subject  has 
been  caught  in  a  soaking  rain,  works  under  ground  or  in  damp  places, 
labors  while  he  leans  or  sits  upon  moist  earth  or  chilled  stone,  goes 
out  improperly  clothed  when  it  is  cold,  exposes  himself  to  drafts  or 
while  in  a  heated  condition,  goes  into  a  cold-storage  plant  or  other 
room  having  a  low  temperature. 

This  type  of  diarrhea  may  follow  subjection  of  all  or  a  part  of  the 
body,  particularly  the  abdomen  or  feet,  to  chilling,  and  the  number 
of  the  evacuations  are  as  frequent  after  slight  chilling  as  when  the 
patient  has  a  severe  or  congestive  chill. 

Few  explanations  have  been  offered  as  to  the  manner  in  which 
"taking  cold"  or  chilling  the  body  causes  increased  evacuations,  and 
these  are  not  convincing.  There  can  be  no  doubt  that  sudden  lower- 
ing of  the  surface  temperature  over  a  portion  of  or  the  entire  body  is 
accompanied  by  contraction  of  the  cutaneous  blood-vessels  which 
leads  to  a  congestion  of  the  internal  organs  (particularly  the  intestine 
and  viscera),  which  favors  an  increased  secretion  of  mucus  similar 
to  that  observed  in  the  nasal  passages  during  attacks  of  cor>za. 
This  explanation  is  not  satisfactory  to  the  author,  because  he  has 
frequently  studied  the  feces  in  these  cases  and  the  mucus  contained 
in  them  has  been  small  in  amount  and  disproportionate  to  the  num- 
ber of  evacuations.  Patients  suffering  from  this  t\pe  of  diarrhea 
ordinarily  have  from  five  to  eight  evacuations  daily,  which  indicates 
that  peristalsis  is  markedly  accelerated,  a  condition  not  likely  to 
follow  intestinal  congestion  alone.  It  is  a  question  if  this  variety  of 
loose  movements  should  not  be  grouped  with  neurogenic  diarrheas, 
but  this  has  not  been  done  because  of  custom,  though  the  author 
considers  that  a  nervous  element  is  the  chief  factor  in  many  of  these 
cases.  Elsewhere  it  has  been  pointed  out  that  psychic  emotions, 
disease  in  distant  organs,  and  sudden  shock  can  reflexly  increase 
the  frequency  and  fluidity  of  the  mo\"ements  b\"  causing  hyper- 
istalsis,  excessive  glandular  acti\it\-.  and  the  transudation  of  fluid 
into  the  bowel. 

If  the  controlling  nerxe-renters  and  intestinal  hltx-qus  mechanism 
can  be  disturbed  through  tin-  mt  thods  enumerated,  there  is  reason  to 
believe  that  diarrhea  from  chilling  may  arise  from  the  same  source, 
and  result  from  the  pronounced  influence  of  cold  upon  the  local 
ner\'es  which  carry  the  impulse  to  the  centers  from  which  it   is  re- 


DRINKING    WATER    AND    COLD    BEVERAGES,    DIARRHEA    FROM       II9 

fleeted  to  the  intestinal  nervous  mechanism  controlling  the  motor  and 
secretory  function  ol  the  bowel.  It  is  possijjle  that  in  some  instances 
autosuggestion  pla\s  a  i)arl,  the  patient  developing  or  affecting  mani- 
festations of  a  "cold"  and  intestinal  disturbances  simply  because  he 
has  been  caught  in  a  rain  or  has  gotten  his  feet  wet. 

In  aggra\'ated  cases  true  intestinal  catarrh  develops  when  the 
movements  contain  a  greater  amount  of  mucus,  and  diarrhea  persists 
for  a  longer  time,  frequently  becoming  chronic. 

The  treatment  of  diarrhea  from  chilling  is  mainly  prophylactic, 
but,  once  contracted,  symptomatic  therapeutic  measures  are  indi- 
cated. When  seen  early,  the  patient  should  be  put  to  bed,  given  hot 
drinks,  surrounded  with  blankets,  and  hot  applications  should  be 
made  to  the  abdomen  to  bring  about  a  normal  surface  temperature 
and  relieve  congestion  within  the  bowel,  or  this  may  be  preceded  by  a 
hot  body  or  mustard  foot-bath.  \\'hen  the  chilly  sensations  continue, 
or  the  patient  has  a  well-developed  cold,  a  combination  of  Dover's 
powder,  gr.  v  (0.30),  and  quinin,  gr.  ij  (0.12),  administered  every 
three  or  four  hours,  is  effective  because  it  arrests  the  chills,  causes  the 
patient  to  perspire,  and  diminishes  the  number  of  evacuations  by 
lessening  the  secretions  and  peristalsis.  When  the  patient  sufifers 
from  cramps  or  aching  pains,  opium,  gr.  h  (0.03),  and  the  extract 
of  belladonna,  gr.  |  (0.008),  or  antikamnia,  phenalgin,  gr.  x  (0.60), 
every  four  hours,  are  serviceable.  Warm,  high,  colonic  water  or 
medicated  irrigations  are  also  useful,  liecause  of  the  soothing  effect 
of  the  heat  upon  the  mucosa  and  its  cleansing  action. 

Drinking  Water  and  Cold  Beverages,  Diarrhea  from. — The  drink- 
ing of  pure  water  ma\-  cause  soft  or  increased  frecjuency  of  the  evacu- 
ations when  it  is  consumed  in  large  amounts  or  is  taken  ice  cold  under 
normal  circumstances,  but  more  particularly  during  hot  weather  or 
when  the  subject  is  overheated,  and  the  same  can  be  said  of  all  cold 
beverages. 

The  drinking  of  large  quantities  of  water  induces  diarrhea  by  me- 
chanically stimulating  peristaltic  contractions  and,  possibly,  glandu- 
lar secretion,  thereby  increasing  the  amount  and  fluidity  of  the  intes- 
tinal contents,  and  by  diluting  the  gastro-intestinal  secretions  which 
interferes  with  digestion.  The  drinking  of  ice-cold  water  and  bever- 
ages favors  loose  movements  because  they  first  induce  a  contraction 
of  the  superficial  vessels  in  the  mucosa,  which  is  followed  by  a  marked 
reaction  and  congestion  of  the  membrane,  which  in  turn  temporarily 
leads  to  an  abnormal  secretion  of  the  gastric  and  intestinal  juices  and 
eventually  to  intestinal  catarrh. 

Elsewhere  the  author  has  pointed  out  how  chilling  of  the  body  sur- 
face acts  upon  the  cutaneous  nerves  and  causes  loose  movements,  and 
here  the  same  rules  hold  good,  except  that  the  cold  comes  directh' 
in  contact  with  the  mucosa  of  the  bowel  instead  of  the  skin. 

In  certain  communities,  particularly  Texas  and  New  Mexico, 
the  earth  contains  a  considerable  amount  of  alkali  that  contaminates 
the  water  of  wells  and  springs,  which,  when  drunk  by  a  stranger  or 


I20  SUNDRY    DIARRHEAS 

person  unaccustomed  to  it,  invariabh'  induces  a  persistent  and  ex- 
hausting form  of  diarrhea.  Drinking  water  containing  other  minerals, 
vegetable  matter,  parasites,  refuse,  or  excreta  is  often  responsible  for 
this  condition  when  it  cannot  be  otherwise  accounted  for. 

The  treatment  consists  in  having  the  patient  drink  less  water  and 
at  a  more  moderate  temperature,  and  when  the  diarrhea  is  due  to 
impure  water  it  should  be  boiled  or  discarded  for  that  which  is  pure. 
Then,  in  case  the  loose  movements  continue,  they  should  be  con- 
trolled or  arrested  by  the  usual  antidiarrheal  remedies,  employed  in 
conjunction  with  bowel  irrigation  when  indicated. 

Sun-  and  Heat-strokes,  Diarrhea  from. — Loose  mo\ements  have 
been  observed  in  these  cases,  both  in  patients  who  ha^"e  reco\'ered 
and  those  who  died,  but  the  evacuations  were  due  more  to  rectal  in- 
continence than  to  affections  involving  the  mucosa  of  the  gastro-in- 
testinal  tract.  Nausea,  vomiting,  headache,  vertigo,  delirium,  loss 
of  consciousness,  stercorous  breathing,  and  coma,  one  or  all,  may 
be  present  and,  in  addition,  the  patient  not  infrequently  suft"ers  from 
rectal  and  vesical  incontinence  or  suppression  of  urine,  all  of  which 
manifestations  may  be  accounted  for  through  the  effect  of  the  sun 
or  heat  upon  the  local  or  general  nervous  mechanism. 

These  sufferers  may  be  attacked  while  exposed  to  the  sun,  but 
there  is  a  somewhat  similar  condition  known  as  heat-stroke,  prone  to 
occur  to  workers  who  are  enclosed  in  buildings  exposed  to  high  tem- 
peratures, such  as  obtain  in  glass-works,  foundries,  boiler-rooms, 
kitchens,  etc.  In  the  latter  (heat-stroke)  the  attack  may  come 
on  suddenly,  gradually,  or  be  preceded  by  loss  of  weight,  weak- 
ness, dizziness,  cramps,  severe  headache,  disturbed  vision,  dry 
skin,  rectal  and  vesical  irritability,  but  when  it  reaches  a  climax, 
there  is  hyperpyrexia,  burning  skin,  delirium,  convulsions,  etc., 
along  with  diarrhea  in  some,  or  involuntary  discharge  of  the  feces  in 
others. 

The  prognosis  is  more  favorable  in  heat-  than  in  sun-stroke. 

The  treatment  of  these  conditions  is  largely  prophylactic,  and  con- 
sists in  having  the  patient  avoid  violent  w^ork  when  the  sun  is  hottest 
or  the  temperature  of  the  room  is  very  high,  using  care  as  regards  his 
food,  and  avoiding  iced  drinks  and  excess  of  fluids.  When  an  attack 
has  occurred,  efforts  should  be  made  to  reduce  the  temperature  by 
placing  the  patient  in  a  cool  room  and  applying  cold  packs.  Stimu- 
lation by  inhalations  of  ammonia  or  amyl  nitrite  should  be  resorted 
to,  and  when  the  patient  has  slightly  recovered  he  should  be  placed 
upon  a  diet  composed  of  skimmed  or  butter-milk,  grape-juice,  and 
broths  until  such  times  as  he  can  consume  semisolids.  For  control 
of  the  cramps  and  diarrhea,  opium  and  belladonna  or  the  ordinary 
diarrheal  remedies  are  indicated,  except  when  the  loose  movements 
result  from  incontinence,  in  which  case  they  do  little  or  no  good ;  and 
the  frequent  involuntary  evacuations  will  continue  until  the  patient 
dies  or  his  general  condition  is  improved  and  muscular  tone  has  been 
restored  to  the  rectovesical  musculature. 


EOSINOPHILIC    DIARRHEA  121 

Old  Age,  Diarrhea  in. — The  dij^eslion  is  always  materially  impaired 
in  ihe  aged,  and  Schlesinger  and  Neumann,  following  Schmidt  and 
Strassburger's  plan  of  test-diet  and  fecal  examination  practised  upon 
30  old  people,  found  that  they  digested  connective  tissue  badly,  but 
handled  muscle-fiber,  cereals,  and  fat  very  well.  Mldcrly  individ- 
uals are  often  afflicted  with  constipation  because  of  imperfect  diges- 
tion and  the  difficulty  with  which  the  intestinal  content  is  propelled 
forward.  In  cases  where  feces  are  permitted  to  collect  and  lie  retained 
to  form  single  or  multiple  compact  fecal  masses,  they  soon  excite  a 
stercoral  diarrhea  which  persists  until  the  offending  scybalous  masses 
have  been  dislodged  and  evacuated. 

Hence  the  treatment  here  consists  in  regulating  the  diet,  giving  an 
after-dinner  pill  to  keep  the  bowel  open,  and  administering  castor  oil 
and  freciuent  high  colonic  enemata  of  soapsuds  or  oil  to  soften  the 
impacted  accumulations  so  that  they  may  be  washed  out.  When  the 
masses  are  large,  hard,  and  located  in  the  sigmoid  flexure  or  rectum, 
they  are  most  quickly  removed  by  introducing  the  sigmoidoscope, 
breaking  them  up  with  a  gouge,  and  then  they  can  easily  be  dislodged 
and  washed  out  by  continuous  irrigation. 

Diarrhea  Nocturna. — (See  Neurogenic  Diarrhea.)  The  caption 
"diarrhea  nocturna"  is  employed  to  indicate  a  type  of  loose  move- 
ments wherein  the  stools  are  watery,  rapidly  succeed  each  other,  and 
are  voided  in  the  early  morning  between  two  and  five  o'clock,  when 
the  patient  is  resting  quietly  in  bed,  which  ought  to  favor  a  diminu- 
tion instead  of  an  increase  in  the  evacuations.  This  condition  prevails 
in  tuberculosis  of  the  intestine  and  elsewhere,  and  ulceration  of  the 
colon  may  or  may  not  cause  the  frequent  and  exhausting  stools.  The 
writer  concedes  tuberculosis  may  produce  a  type  of  diarrhea  with 
similar  symptoms,  but  on  several  occasions  he  has  treated  patients 
for  diarrhea  nocturna  who  had  no  organic  lesion  of  the  intestine,  but 
suffered  some  organic  or  functional  disease  of  the  nervous  system, 
where  the  evacuations  were  watery,  frecfuent,  and  occurred  in  the 
early  morning,  and  in  whom  the  diarrheal  state  was  aggravated  by 
anxiety,  sorrow,  business  worries,  and  psychic  emotions  of  all  kinds. 
Hence  he  holds  that  nocturnal  should  be  grouped  with  the  other  neuro- 
genic diarrheas  discussed  elsewhere. 

Eosinophilic  Diarrhea. — Neubaucr  and  Staubli^  have  reported 
cases  of  this  type  of  acute  diarrhea  with  marked  constitutional  symp- 
toms in  which  the  mucosa  was  highly  inflamed.  During  the  height 
of  the  attack  the  eosinophils  completely  disappeared  from  the  blood 
and  returned  when  the  symptoms  abated.  All  cases  occurred  in  young 
adults,  and  were  acccjmpanied  by  severe  diarrhea,  with  blood,  mucus, 
and  Charcot-Leyden  crystals  in  the  stools.  Intestinal  parasites, 
specific  bacteria,  or  gonococci  were  found.  The  rectal  mucosa  was 
congested  and  covered  here  and  there  with  whitish  exudates,  but  was 
not  ulcerated. 

These  cases  would  indicate  that  the  claim  made  by  many  authors 
'Munch.  Med.  Wochcnschrifl,  1906,  p.  2380. 


122  SUNDRY    DIARRHP:AS 

to  the  effect  that  Charcot-Leyden  crystals  in  the  stools  and  an  in- 
creased number  of  eosinophils  in  the  blood  are  ahva>s  indicati\c  of 
intestinal  parasites  does  not  obtain. 

Tile  treat nicul  is  local  and  general. 

Mechanic  Diarrhea. — Like  others,  mechanic  stimuli  irritate  the 
mucosa  and  tend  to  augment  the  mucous  glands  to  excessive  activity 
and  increase  the  frequency  and  strength  of  the  peristaltic  movements. 
Consequently,  mechanic  diarrhea  may  be  induced  by  foreign  bodies, 
enteroliths,  gall-stones,  intestinal  sand,  scybahe,  large  impacted 
fecal  masses,  swallowing  of  metal-dust,  drinking  water  contaminated 
by  the  feces  of  grasshoppers  (Prout),  decomposing  granite  (Harti- 
gan),  or  lime-dust. 

The  treatment  consists  in  eliminating  the  source  of  the  irritation, 
and  then  treating  the  patient  as  if  he  had  enterocolitis. 

Reflex  Disturbances,  Diarrhea  in. — Sometimes  loose  movements 
from  this  source  are  incident  to  disease  or  a  growth  involving  neigh- 
boring organs  (particularly  sexual)  distant  from  the  gastro-intestinal 
tract  which  it  indirecth'  disturbs.  Gastro-intestinal  indigestion  and 
diarrhea  may  result  from  an  ulcer  in  the  stomach  or  stricture  in  the 
rectum  which  impairs  the  functions  of  the  stomach;  the  small  intes- 
tine and  colon  may,  through  reflex  disturbances,  be  seriously  interfered 
with  when  a  small  segment  of  the  alimentary  canal  has  become  ptotic 
or  diseased,  or  involved  b\-  adhesions,  an  angulation,  invagination, 
twist,  pericolic  membrane,  diverticulum,  or  blocked  by  a  tumor, 
stricture,  or  foreign  body. 

Diseases  or  injury  of  the  brain,  spinal  cord,  or  nerves  remote  from 
the  bowel  may,  under  favorable  circumstances,  lead  to  watery  evacu- 
ations or  anal  incontinence,  and  emotional  disturbances,  as  excite- 
ment, fright,  joy,  and  worry,  frequently  cause  diarrhea.  Many 
other  causes  of  reflex  diarrhea  could  be  mentioned,  but  it  is  not  neces- 
sary here  to  more  than  recall  the  fact  that  surgeons  have  in  hundreds 
of  instances  succeeded  in  permanently  curing  chronic  reflex  diarrhea 
by  operating  and  removing  the  cause  of  irritation  to  the  local  or 
general  nerve  mechanism  which  through  reflex  disturbances  were 
responsible  for  the  diarrhea. 

Acute  Embolic  Enteritis  and  Colitis,  Diarrhea  in. — Like  other 
organs  the  large  and  small  intestine  may  become  involved  through 
hematologic  emboli  in  the  presence  of  ulcerative  endocarditis,  anthrax, 
septic  angina,  fibrinous  pneumonia,  and  other  pyogenic  processes. 

Changes. — While  the  submucosa  later  is  primarily  attacked,  the 
mucosa  becomes  softened,  edematous,  and  characterized  at  first  by 
punctiform  hemorrhagic  foci,  or  scattered  nodules  having  hemor- 
rhagic margins,  and,  later,  by  phlegmonous  ulceration  or  abscess  in 
the  region  of  the  vessels  blocked  by  bacterial  emboli. 

The  method  of  diagnosing  and  localh-  treating  embolic  entero- 
colitis resembles  that  of  ulcerative  and  phlegmonous  entamebic 
colitis,  discussed  elsewhere. 


CHAPTKR   X 

GASTROGENIC  DIARRHEA   (DYSPEPTIC  DIARRHEA, 
LIENTERIC  DIARRHEA) 

ACHYLIA    GASTRICA.    HYPERACIDITY,   MALIGNANCY,   ATONY,  MOTOR 

INSUFFICIENCY 

Comparatively  a  few  years  ago  nearly  all  diarrheas  were  re- 
garded as  being  due  to  functional  or  organic  disease  of  the  intestine, 
but  today  it  is  conceded  that  this  condition  is  sometimes  caused  by 
disease  of  the  stomach  or  interference  with  the  gastric  secretions  from 
nervous  and  other  causes,  and  to  Einhorn,  Oppler,  Schultz,  and  A. 
Schmidt  belongs  the  chief  credit  for  having  pointed  out  this  type  of 
diarrhea,  explained  its  etiolog\',  outlined  a  rational  method  of  diagno- 
sis, and  suggested  measures  for  its  correction.  Except  in  typical  cases 
it  is  often  extremeh'  difficult  to  determine  the  exact  part  played  by 
abnormalities  of  the  stomach  in  diarrhea  gastrica,  because  in  some 
instances  the  stomach  is  soleh'  responsil)le,  in  others  there  is  associ- 
ated disturbance  of  the  duodenum  and  pancreas,  or  a  catarrhal  condi- 
tion of  the  small  or  large  l.)owel,  which  help  to  increase  frecjuency  of 
the  movements. 

This  type  of  diarrhea  ma\'  be  induced  b\-  achylia  i^astrica  {sub- 
acidity),  hyperacidity,  atony,  motor  insufficiency  ot  the  stomach  or 
mali'^nancy,  either  of  which  may  temporarily  or  i)ermanentl\-  imi)air 
the  functionating  power  of  the  intestine,  particularly  when  it  is  al- 
ready affected  or  the  patient  has  a  lowered  resistance. 

In  this  affection  there  is  usually  but  a  slight  discomfort  in  the 
stomach,  the  diarrheal  manifestations  being  the  chief  source  of 
trouble  and  from  which  the  patient  desires  relief. 

In  achylia  gastrica  diarrhea,  owing  to  the  absence  ot  Indrochloric 
acid,  that  part  of  the  digestion  assigned  to  the  stomach  fails  to  take 
place,  and  the  improperly  prepared  chyme  is  discharged  into  an  ott- 
times  already  irritable  or  nervous  intestine  which  is  incapable  ot  com- 
pleting digestion  on  account  of  the  extra  work  thrown  upon  it.  Ton- 
sequently,  it  is  not  surprising  that  this  abnormal  intestinal  content, 
with  its  large  boluses  and  abundant  undigested  connecti\-e-tissue  rem- 
nants, should  irritate  the  intestinal  mucosa  to  magnify  its  secretions 
and  reflexly  stimulate  a  more  frequent  and  stronger  peristalsis  which 
invariably  leads  to  increased  frequency  of  the  evacuations.  Again, 
the  bactericidal  quality  of  the  chyme  is  materially  reduced  through 
loss  of  the  Indrochloric  acid,  which  allows  the  putrefacti\e  and  other 
pathogenic  bacteria  inhabiting  the  intestine  to  multij:)ly  and  de\-elop 
^•irulent  toxins  with  a  tendenc\-  to  aggravate  the  diarrlu-al  condition, 

123 


124  GASTROGEXIC    DIARRHEA 

and  it  would  appear  that  the  connective-tissue  food  remnants  afford 
the  bacteria  an  excellent  medium  in  which  to  develop. 

Hydrochloric  acid  is  known  to  stimulate  pancreatic  activity,  and 
because  of  this  lost  influence  the  amount  of  pancreatic  juice  is  materi- 
ally diminished,  which  in  itself  is  often  sufficient  to  induce  aggravated 
diarrhea. 

Hyperacidity  (though  less  frequently  than  achylia)  is  an  etiologic 
factor  in  gastrogenic  diarrhea.  In  these  cases  there  is  a  marked  in- 
crease in  the  amount  of  hydrochloric  acid  present,  while  the  organic 
acids  show  but  slightly  if  at  all.  and  there  is  a  characteristic  lessening 
in  the  amount  of  bile  secretion.  In  discussing  the  manner  by  which 
hyperacidity  diarrhea  is  produced,  Gaultier  maintains  that  in  these 
cases  the  hypersecreted  chyme  succeeds  only  ver>'  slowh'  and  imper- 
ceptibly in  saturating  its  hydrochloric  acid  in  the  digestive  passages, 
so  that  the  fermentation  acids  which  already  exist  in  the  stomach, 
increased  by  the  fermentation  acids  which  normally  form  in  the  intes- 
tine through  the  decomposition  of  the  fatty  substances,  react  upon  the 
intestinal  mucosa  and  lead  to  hypersecretion  and  peristaltic  activity 
by  irritation  of  the  ner\-e-fibers.  the  peristalsis  finally  becoming 
strong  enough  to  induce  frequent  and  liquid  stools. 

Peculiarly  enough,  this  condition  produces,  or  at  least  is  asso- 
ciated with,  a  considerable  lessening  of  the  flow  of  bile,  a  change  which 
favors  an  increase  of  the  diarrheic  condition  because  the  stimulating 
effect  of  the  bile  upon  pancreatic  secretion  is  minimized,  the  neu- 
tralizing effect  of  its  alkaline  qualities  upon  the  upper  intestinal  acid 
contents  is  diminished,  and  modifies  fat  absorption,  all  of  which  inter- 
fere with  the  digestion  and  assimilation  of  food,  thereby  leaving  an 
abnormal  and  larger  residue  which  favors  putrefaction,  increased  secre- 
tion of  mucus,  sets  up  marked  peristaltic  action,  and  brings  about  diar- 
rhea. Gaultier  has  called  attention  to  the  fact  that  acid  diarrheas  are 
associated  w^ith  duodenal  dystr\psia,  which  alternates  with  consti- 
pation, and  says  that  the  former  is  the  result  of  deficient  pancreatic, 
and  the  latter  to  a  lessening  of  bilian.-,  secretion. 

In  the  atonic  and  deficient  motility  types  of  gastrogenic  diarrheas 
the  manner  in  which  the  frequent  movements  are  excited  have  not 
been  satisfactorily  explained,  but  it  is  probable  that  the  food  and 
secretions  remain  until  stagnant;  in  the  meantime  abnormal  fer- 
mentation and  putrefaction  take  place  and  the  bacteria  and  toxins 
increase  and  cause  trouble.  Finally,  when  all  or  a  part  of  the  incom- 
pletely digested  gastric  contents,  along  with  the  irritative  gases  formed, 
are  discharged  into  the  small  intestine,  they  profoundly  effect  the 
delicate  mucosa,  directly  by  contact  and  indirectly  through  action  of 
the  toxins  upon  the  nervous  system,  with  the  result  that  intestinal 
digestion  is  interfered  with,  assimilation  is  diminished,  intestinal 
glands  are  excited  to  excessive  activity,  and  the  bowel  is  left  in  an 
irritable  state  and  peristalsis  readily  responds  to  trauma  induced  by 
the  food  remnants. 

Carcinoma  of  the  stomach  may  also  be  classed  among  the  causes 


SYMPTOMS  125 

of  gastrogcnic  diarrhea.  When  located  in  the  body  of  the  cardiac 
end  of  the  stomach  the  (hsiurbance  is  due  to  fermentative  changes 
and  diminished  hydrochloric  acid,  but  malignancy  usually  attacks 
the  pyloric  end  of  the  stomach,  and  under  such  circumstances  there 
is  impaired  digestion,  aclnlia  gastrica,  and  obstruction  that  causes 
retention  and  stagnation  of  the  food,  which  when  discharged  into 
the  bowel  sets  u{>  an  irritative  diarrhea. 

Certain  organisms,  like  \east,  fungi,  proteus,  bacilli,  cocci,  and 
streptococci  of  various  kinds  and  forms,  are  usually  found  in  large 
numbers  in  the  feces  of  patients  suffering  from  gastro-intestinal  dys- 
peptic diarrhea,  and  it  is  reasonable  to  suppose  that  one  or  all  play  a 
greater  or  less  part  in  exciting  this  condition,  and  the  first  two  are 
frequently  encountered  in  enormous  amounts. 

Symptoms. — Patients  afflicted  with  gastrogenic  diarrhea  sufi"er 
but  slighth'  from,  and  consequently  place  but  little  importance 
upon,  gastric  manifestation,  but  complain  bitterly  of  the  diarrhea, 
and  many  of  them  become  hypochondriacs  and  think  and  talk  of 
nothing  but  their  intestinal  ailment,  much  of  the  worry  being  due 
to  the  fact  that  it  is  thought  incurable  because  of  its  chronicity. 
Sometimes  this  type  of  loose  movements  is  continuous,  but  occasionally 
after  dietary  indiscretions  the  attack  may  occur  at  shorter  or  longer 
periods  or  be  continuous,  according  to  the  nature  and  gravity  of  the 
case,  and  those  of  an  extremely  nervous  constitution  suffer  greatest 
and  have  more  freciuent  passages  than  those  who  are  not. 

Early  in  diarrhea  gastrica  the  intestine  is  not  involved,  but  later 
become  so,  and  an  enteritis  or  enterocolitis  gradually  develops  through 
trauma  and  constant  irritation  to  the  mucosa;  in  severe  cases  mucus, 
pus,  and  blood  complicate  the  symptom-complex.  The  lienteric 
character  of  the  stools  is  the  chief  manifestation  in  all  forms  of  gastro- 
genic diarrhea,  because,  as  A.  Schmidt  and  others  have  repeatedly 
shown,  the  feces  contain  undigested  connective-tissue  remnants. 

The  fact  has  already  been  mentioned  that  in  the  hyperacidity 
type  of  gastrogenic  diarrhea  there  is  a  deficiency  in  both  the  biliary 
and  pancreatic  fluids.  In  such  cases  there  is  little  or  no  anorexia, 
but  the  patient  suffers  from  a  ccjated  tongue,  waxy  at  first,  and  later 
greenish  complexion;  gas  distention,  tenderness  over  the  stomach 
and  small  intestine,  weakness  and  loss  of  weight,  restlessness,  has 
little  if  any  desire  to  attend  to  his  social  or  business  duties,  and  the 
acid,  watery,  frequent  evacuations  induce  annoying  tenesmus  and 
irritate  the  skin,  but  when  there  is  complete  absence  of  the  pancreatic 
fluid  the  movements  contain  an  abundance  of  fat;  bright  droplets 
are  visible  to  the  naked  eye,  as  are  remnants  of  starch  and  meat. 

It  has  been  demonstrated  conclusively  that  diarrhea  does  not 
always  occur  in  connection  with  the  above-described  gastric  ab- 
normalities, and  because  of  this  Schutz  claims  that  when  it  does,  the 
bowel  has  a  lowered  resistance. 

Where  the  gastric  changes  lead  to  fermentative  diarrhea  the  symp- 
toms are  disseminated,  the  patient  claiming  loss  of  appetite,  malaise, 


126  GASTROGENIC    DIARRHEA 

central  abdominal  tenderness,  pain,  borborygmus,  moderate  diarrhea 
with  light  yellow,  pasty,  and  foamy  evacuations  having  an  acid  re- 
action and  a  foul  odor,  and  containing  starch  and  connective-tissue 
remnants. 

In  diarrhea  gastrica  consequent  upon  carcinoma,  constipation  is  an 
early  manifestation,  and  later  alternates  with  diarrhea,  but  in  the 
terminal  stages  frequent  movements  prevail  in  half  the  cases,  and 
the  number  of  stools  is  increased  when  the  patient  eats  copiously 
of  indigestible  foods,  and  diminished  under  a  restricted  diet  dominated 
by  fluids. 

Gastrogenic  diarrhea  may  be  suspected,  but  cannot  be  proved, 
when  the  gastric  secretions  vary  slightly  and  examination  of  the 
stools  demonstrate  the  absence  of  pus,  blood,  and  mucus.  Authori- 
ties best  qualified  to  speak  are  inclined  to  consider  diarrheas  which  are 
preceded  by  chronic  gastric  disturbances,  those  improved  by  the 
administration  of  hydrochloric  acid  or  gastric  lavage,  where  the 
stools  contain  pieces  of  meat  or  finer  connective-tissue  remnants,  or 
large  numbers  of  yeasts,  sarcinse,  long  bacilli,  proteus,  and  other 
fermentative  or  putrefactive  producing  organisms,  as  being  partially 
or  entirely  due  to  achylia  gastrica,  hyperacidity,  atony,  insufiicient 
motility,  or  gastric  malignancy. 

Diagnosis. — To  A.  Schmidt  more  than  anyone  else  belongs  the 
credit  for  devising  a  rational  method  of  differentiating  gastrogenic  (lien- 
teric)  from  other  diarrheas,  for  he  has  shown  by  his  test-meal  that  con- 
nective-tissue remnants  are  found  in  all  types  of  diarrhea  gastrica,  while 
Einhorn,  Oppler,  Schutz,  and  others  have  done  much  to  isolate  the 
different  types  of  gastrogenic  diarrhea  by  demonstrating  that  they 
are  due  respectively  to  achylia  gastrica,  hyperacidity,  atony,  and 
motor  insufficiency,  and  that  they  are  demonstrable  by  an  examina- 
tion of  the  stomach  and  its  secretions. 

The  main  reliance  in  the  diagnosis  consists  in  an  analytic  study 
of  the  feces  following  a  test  diet  of  two  or  three  days'  duration  or  such 
time  as  an  evacuation  from  it  can  be  obtained.  A.  Schmidt's  itinerary 
is  the  best,  and  consists  of  milk,  toast,  oatmeal,  eggs,  beef,  mashed 
potatoes,  and  butter.  After  such  a  diet  the  stool  is  placed  in  a  vessel 
with  water  and  macerated,  and  then,  if  connective-tissue  shreds  are 
visible  on  microscopic  examination,  it  demonstrates  the  gastrogenic 
nature  of  the  diarrhea,  as  in  achylia  gastrica,  etc.  The  analysis  also 
shows  imperfectly  digested  vegetables,  fats,  and  albuminoids,  biliary 
deficiency,  and  when  there  is  intestinal  irritation,  glairy  mucus  and 
discarded  epithelial  cells. 

Schmidt  has  also  pointed  out  that  the  abundant  presence  of 
micro-organisms  which  produce  fermentation  and  decomposition, 
such  as  yeasts,  sarcinw,  long  bacilli,  and  others  already  alluded 
to,  is  additional  evidence  of  gastric  disturbance. 

When  diarrhea  gastrica  is  due  to  hyperacidity  or  other  abnor- 
mality, is  complicated  by  deficient  pancreatic  secretion  or  achylia, 
the   movements   following   the   test-diet   show   an   abundance  of  fat 


DIACiNOSIS  127 

droplets,  microscopic  particles  of  meat,  connective-tissue  shreds, 
starch,  and  microscopicalK'  demonstrable  connective-tissue  nuclei; 
the  latter  being  digestible  only  by  pancreatic  secretion,  consequently 
Schmidt  maintains  that  their  presence  always  indicates  pancreatic 
disturbance. 

Independent  or  associated  fermentative  dyspepsia  is  recognized 
by  the  symptom-complex  already  enumerated  and  the  coprologic 
findings,  such  as  yellow,  pasty,  foamy,  disagreeable  acid  stools,  which 
contain  large  amounts  of  starch  remnants  and  colostrum  butyricum 
(Zwieg),  and  their  incubator  test  shows  a  marked  carbohydrate  fer- 
mentation (Kuttner).  Small  intestinal  fermentation  and  putrefac- 
tion, according  to  Schmidt,  may  continue  after  the  gastric  error  has 
been  corrected. 

Enteritis,  or  enterocolitis,  may  be  present  before  or  de\elop 
on  the  basis  of  a  chronic  gastrogenic  diarrhea,  under  which  circum- 
stances abnormality  of  the  gastric  contents  is  manifest,  connective- 
tissue  remnants  are  present  in  the  feces  besides  mucus,  or  in  aggra- 
vated cases,  pus  and  blood,  which  indicate  a  catarrhal  condition  of 
the  intestine,  and,  in  addition  to  these  diagnostic  signs,  the  patient 
complains  of  cramps  and  frequently  suffers  from  auto-intoxication. 

Biliary  insufficiency,  which  often  complicates  hyperacidity  and 
other  lorms  of  gastrogenic  diarrhea,  is  indicated  in  the  fecal  analysis 
by  poorly  digested  fats,  muscle-fibers  slightly  stained  with  l)ile,  and 
a  weak  Gmelin  reaction. 

Gastrogenic  diarrhea,  induced  by  an  ulcer  ( peptic j  in  the  stomach, 
is  characterized  by  sitophobia  inducing  epigastric  pain  following  eat- 
ing, tenderness  upon  pressure  in  the  epigastrium,  indigestion,  vomit- 
ing, which  affords  relief,  hemorrhage,  pyloric  spasm,  collapse,  anemia 
when  bleeding  has  been  copious,  and  manifestations  of  shock  and 
peritonitis  following  perforation. 

Cancer  of  the  stomach  is  usually  located  at  the  pylorus,  though 
it  may  involve  the  lesser  cur\-ature  or  cardia,  and  can  be  differentiated 
from  other  affections  because  it  is  prone  to  occur  in  middle  age  or 
elderly  persons,  induces  se\ere  dragging  pains  in  the  epigastric  region 
or  back,  vomiting  of  undigested  food,  bleeding,  metastasis  of  the  ab- 
dominal lymph-nodes;  the  patient  is  cachectic,  has  indicanuria, 
there  is  frequently  visible  peristalsis,  and  when  ad\"anced  a  unnor 
can  be  made  out  by  percussion  or  detected  1)\'  palpation;  again,  in 
such  cases  a  test-meal  analysis  shows  that  HCl  and  ferments  are 
diminished,  while  lactic  and  fatty  acids  are  abundant.  Macroscopic 
and  microscopic  examination  of  the  stomach  contents  show  bright 
or  clotted  blood,  pus,  mucus,  shreds  of  tissue,  and  the  Oppler-Boas 
bacillus  and  sarcinec.  Cancer  of  the  pylorus  is  complicated  by  stag- 
nation of  the  stomach  contents,  and  lactic  acid  fermentation  or  hydro- 
chloric acid  is  present  when  it  results  from  degeneration  of  a  pyloric 
ulcer. 

With  a  normal  gastric  content  and  no  connective-tissue  remnants, 
fat,  mucus,  pus,  or  blood  in  the  stools,  persistent  loose  movements 


128  GASTROGENIC    DIARRHEA 

simulating  those  of  diarrhea  gastrica  should  be  diagnosed  neurogenic 
diarrhea. 

Treatment. — From  what  has  been  said  about  the  etiology  of 
gastrogenic  diarrheas  it  is  obvious  that  a  routine  treatment  is  im- 
practicable, because  in  different  cases  the  stomach  is  atonic,  there 
is  motor  insufficiency,  its  contents  are  abnormal,  there  is  Ijiliary  and 
pancreatic  insufficiency,  and  enteritis  may  be  a  complication;  all  of 
which  conditions  require  consideration  when  a  plan  of  treatment  is 
to  be  outlined.  In  this  condition  it  is  very  difficult  to  resist  prescrib- 
ing for  the  diarrhea  and  intestinal  manifestations  which  dominate  the 
clinical  picture,  but  to  be  effective  this  must  not  be,  and  the  treat- 
ment should  be  directed  against  the  gastric  abnormality  or  true  source 
of  the  trouble. 

When  diarrhea  gastrica  is  consequent  upon  achylia  or  diminished 
acidity,  liberal  doses  of  hydrochloric  acid  or  natural  gastric  juice  should 
be  administered  three  times  daily  at  mealtime,  and  this  agent  is  also 
the  most  effective  remedy  to  prescribe  in  the  absence  of  a  changed 
secretion  when  there  is  atony  or  impaired  motility  of  the  stomach,  but 
in  these  conditions  Schmidt  recommends  that  a  bitter  tonic  be  com- 
bined with  it. 

Loose  movements  consequent  upon  hyperacidity  are  best  con- 
trolled by  alkaline  and  sedative  preparations  to  neutralize  excess  of 
the  acid,  limit  the  secretion,  and  diminish  intestinal  irritability,  such 
as  the  bicarbonate  of  soda,  magnesia,  charcoal,  bismuth,  cerium 
oxalate  and  calcium,  either  alone  or  in  combination  with  belladonna, 
but  when  this  condition  is  complicated  by  abnormal  amounts  of  fats 
in  the  feces  one  of  the  reliable  pancreatic  digestants  should  be  ad- 
ministered to  overcome  the  deficiency. 

In  the  fermentative  type  of  gastrogenic  diarrhea,  magnesium  per- 
oxid  has  proved  very  satisfactory,  and  regarding  its  action  Gaultier 
says,  "This  substance  has  the  property  of  decomposing,  in  an  acid 
medium,  into  a  neutral  salt  of  magnesium  and  oxygenated  water. 
The  oxygenated  water,  in  its  turn,  permits  the  escape  of  nascent 
oxygen  into  the  intestine,  which  probably  inhibits  intestinal  fermen- 
tations." Bismuth  and  charcoal  are  also  useful  agents  to  employ 
in  gastro-intestinal  dyspepsia,  but  while  waiting  for  medicines  to 
accomplish  their  purpose  much  can  be  done  to  relieve  diarrhea  and 
other  uncomfortable  manifestations  by  keeping  the  patient  in  bed, 
applying  hot  applications  to  the  abdomen,  and  restricting  the  diet. 

While  it  is  necessary  to  pay  attention  to  the  diet,  this  part  of  the 
treatment  of  diarrhea  gastrica  is  not  nearly  so  important  as  it  is  in 
some  other  diseases  of  the  stomach.  Indigestible  foods  may  aggra- 
vate the  condition,  but  the  evacuations  are  apt  to  occur  with  increased 
frequency  in  this  class  of  cases  immediately  after  meals,  irrespective  of 
what  has  been  eaten.  It  is  important  to  see  that  the  food  is  well 
prepared  and  carefully  masticated,  to  limit  the  amount  of  meat  con- 
sumed (and  interdict  it  altogether  when  raw  or  smoked),  for  otherwise 
the   patient's   condition   will    invariably   be   aggravated.     A   protein 


TREATMENT 


129 


diet  is  most  suitable  in  fermentative  diarrheas,  but  where  there  is  a 
hyperacidity,  with  pancreatic  and  biUary  insufficiency,  fats  should 
be  restricted  and  the  bile  tlow  sliinulated  by  the  administration  of 
roast  meats  and  eggs. 

In  gastrogenic  diarrhea  consecjuent  upon  carcinoma,  control  of 
the  diet  is  of  great  importance,  and  only  foods  which  cause  the  least 
irritation  and  pain  should  be  permitted,  and  they  should  be  taken  in 
small  cjuantities  and  at  short  intervals. 


Fig.  26. — Washing  out  the  stomach. 


Where  there  is  gastric  atony  or  diminished  motility,  and  the  treat- 
ment already  outlined  fails,  open-air  exercise,  massage,  electric  vi- 
bratory treatments,  and  hydrotherapy  often  render  valuable  assist- 
ance by  strengthening  the  organ.  Patients  afflicted  with  this  type  of 
diarrhea,  who  suffer  greatly  from  gastric  stagnation,  fermentation, 
and  putrefaction,  resulting  from  imperfect  secretions  or  malignant 
pyloric  stenosis,  are  relieved  by  nightly  or  more  frequent  gastric 
lavage  (Fig.  26).  A  normal  saline  or,  in  suitable  cases,  an  alkaline 
solution  is  employed.  When  enteritis  or  colitis  is  present,  as  is  evi- 
denced by  mucus,  pus,  or  blood  in  the  stools,  much  can  be  done  toward 
9 


I30  GASTROGENIC    DIARRHEA 

the  patient's  comfort  by  minimizing  intestinal  auto-intoxication,  and 
healing  the  inflamed  mucosa  by  colonic  enteroclysis,  using  boric  acid, 
2  per  cent.;  ichthyol,  balsam  of  Peru,  i  per  cent.,  or  permanganate 
of  potassium,  i  per  cent.;  or  permitting  |  pint  of  olive  oil  containing 
I  oz.  of  glycerin  to  flow  into  the  bowel  at  night  three  times  weekly  or 
oftener. 

Gastrogenic  diarrhea  is  peculiar,  in  that  the  usual  antidiarrheal 
remedies  fail  to  control  the  movements  and  are  contra-indicated, 
except  opium  extract,  gr.  I  (0.015),  or  this  drug  and  belladonna 
extract,  gr.  |  (0.008),  when  the  evacuations  are  exceedingly  frequent 
and  the  patient  suffers  intensely  from  abdominal  pains  and  cramps. 

Patients  who  suffer  from  diarrhea  incident  to  gastric  ulcer  should 
be  put  to  bed  for  several  weeks,  and  kept  on  a  fluid  diet  reinforced 
by  nutritive  enemata;  the  bowel  should  be  kept  open  by  small  doses 
of  Carlsbad  or  Epsom  salts,  administered  daily;  opium  or  morphin, 
gr.  I  (0.015),  employed  to  relieve  pain,  and  astringents  and  antisep- 
tics, as  bismuth,  gr.  xx  (1.30);  silver  nitrate,  gr.  |  (o.oi);  or  tannalbin, 
gr.  X  (0.60),  should  be  prescribed  three  times  a  day  to  diminish  the 
stools  and  stimulate  healing  of  the  ulcer.  When  there  is  hyper- 
acidity, alkaline  remedies,  such  as  sodium  carbonate,  gr.  xx  (1.30), 
should  be  administered  in  liberal  doses  in  addition  to  the  mineral  waters 
already  mentioned,  and  when  the  patient  is  anemic  Fowler's  solution 
of  arsenic,  m  iv  (0.24),  should  be  added  to  the  treatment;  when  bleed- 
ing is  profuse,  extreme  quiet  is  indicated,  the  ice-bag  should  be  ap- 
plied over  the  stomach,  and  ergot,  mj  xv  (i.o),  given  hypodermically, 
and  hypodermoclysis  administered  if  necessary. 

In  cases  where  rest,  hygienic,  dietetic,  and  medicinal  measures 
fail  to  effect  a  cure,  one  should  immediately  resort  to  gastro-enteros- 
tomy,  gaslrodiiodenostomy,  or  pyloroplasty  when  the  lesion  is  at  the 
pylorus,  and  when  there  is  perforation  the  opening  in  the  stomach 
should  be  closed  independently  or  in  conjunction  with  enterostomy. 

Carcinoma  invariably  terminates  fatally,  except  when  the  growth 
is  removed  by  a  radical  operation  which  necessitates  resection  of  a 
small  or  considerable  portion  of  the  organ,  and  in  some  instances 
complete  extirpation  of  the  stomach  {partial  or  complete  gastrectomy). 

Palliative  treatment  is  indicated  in  the  majority  of  cases  because 
they  reach  the  inoperable  stage  before  the  nature  of  the  trouble  has 
been  determined.  Such  measures  consist  in  restricting  the  patient 
to  a  selective  fluid  or  non-irritating  diet,  preventing  gastric  fermen- 
tation, and  administering  opiates  in  liberal  doses  alone  or  in  con- 
junction with  antiseptics,  astringents,  and  styptics  to  control  pain, 
diminish  frequency  of  the  evacuations,  and  minimize  the  danger  from 
hemorrhage.  Cocain  or  orthoform  added  to  the  prescription  affords 
the  patient  additional  relief. 

In  the  presence  of  stagnation,  distention  from  gas,  and  excessive 
fermentation  relief  in  some  instances  quickly  follows  gastric  lavage. 
When  well  borne,  hydrochloric  acid  may  be  prescribed  to  advantage 
to  increase  the  efficiency  of  the  gastric  contents,  and  tonic  remedies 


TREATMENT  I3I 

should  be  administered  to  stimulate  the  appetite  and  strengthen  the 
patient. 

When  these  measures  fail,  the  patient  grows  steadily  worse,  and 
his  suffering  becomes  unbearable,  palliative  operations  are  justified, 
but  the  patient  or  his  friends  must  be  told  that  the  operation  will 
diminish  suffering  and  extend  life,  but  that  in  no  case  will  it  effect  a 
cure.  When  the  cancer  is  located  at  the  cardiac  extremity  of  the 
stomach,  causes  obstruction,  and  makes  it  extremely  difficult  for 
the  patient  to  swallow  fluids,  gastrostomy  is  indicated  and  affords 
almost  instantaneous  relief,  and  is  followed  by  improvement  in  the 
patient's  general  condition,  because  he  can  be  comfcjriahK-  fed  at  any 
time  through  the  artificial  opening. 

Gastro-enterostomy  is  the  operation  of  choice  in  inoperable  cases 
where  the  tumor  is  located  at  or  near  the  pylorus,  irrespective  of 
whether  or  not  obstruction  has  occurred.  This  procedure  prevents 
gastric  stasis  and  undue  fermentation,  lessens  the  danger  from  bleed- 
ing, furthers  digestion,  relieves  pain,  and,  to  some  extent,  inhibits 
growth  of  the  tumor  by  minimizing  the  trauma  to  it.  When  the  can- 
cer is  small  and  has  not  progressed  too  far.  the  operation  is  frequently 
a  valuable  preliminary  step  to  extirpation,  because  in  the  interval 
between  the  operations  the  debilitated  state  of  the  patient  and  irri- 
table condition  of  the  stomach  can  be  improved,  since  disturbances 
consequent  upon  passage  of  the  food  through  the  strictured  segment 
of  the  stomach  are  relieved.  E.xcept  when  the  posterior  wall  is  in- 
volved by  the  disease  or  adhesions,  posterior  is  preferable  to  anterior 
gastro-enterostomy.  In  extreme  cases,  where  the  patient  is  sorely 
afflicted  with  pain  and  nourishment  other^vise  is  impossible,  and 
gastro-enterostomy  is  for  any  reason  impracticable,  jejunostonty  is 
called  for.  Under  other  circumstances  this  operation  is  contra-indi- 
cated, because  it  is  impossible  to  introduce  a  sufficient  amount  of 
nourishment  through  the  opening,  and  because  the  fluid  chyme  is 
being  constantly  discharged  through  the  opening  to  annoy  the  patient 
and  irritate  the  skin. 


CHAPTER   XI 

ENTEROGENIC  DIARRHEA  (DYSPEPTIC  DIARRHEA,  LIEN- 
TERIC   DIARRHEA) 

UNBALANCED  SUCCUS   ENTERICUS,   DUODENAL  ULCER 

Dyspepsia  intestinalis  occurs  more  frequently  than  is  generally 
supposed,  because  the  diarrhea  from  this  source  is  frequently  attrib- 
uted to  gastrogenic  disturbances  or  to  various  inflammatory  and 
ulcerative  lesions  of  the  colon.  Enterogenic  dyspeptic  loose  move- 
ments may  be  marked  in  individuals  when  the  mucosa  is  broken  and 
when  it  is  not,  but  usually  it  is  more  aggravated  and  dilificult  to  control 
in  the  former  than  the  latter. 

This  type  of  diarrhea  may  be  primary  when — (a)  it  is  due  to  a  di- 
minished secretion  of  the  biliary,  pancreatic,  or  true  intestinal  secre- 
tions; ib)  they  are  prevented  from  being  discharged  into  the  duodenum 
owing  to  obstruction  within  the  ducts;  (c)  there  are  pathogenic  changes 
in  the  mucosa  which  interfere  with  or  prevent  intestinal  digestion  and 
assimilation ;  and  {d)  there  are  imperfect  mastication  and  indiscretions 
in  diet,  and  more  food  is  consumed  than  the  intestinal  juices  can 
take  care  of.  Indigestible  articles  of  diet  (cabbage,  sour-krout,  cu- 
cumbers, and  fresh  fruit),  after  passing  through  the  stomach,  are 
mechanically  irritative,  or  readily  undergo  fermentation  and  putre- 
faction. 

Intestinal  dyspepsia  may  be  secondary  to  gastrogenic  functional 
and  organic  diseases,  such  as  (a)  hyperacidity,  {b)  achylia,  (c)  atony, 
{d)  impaired  motility,  and  {e)  benign  or  malignant  obstruction,  which 
induces  intestinal  catarrh  or  imperfect  digestion,  owing  to  the  action 
of  the  abnormal  gastric  juice  upon  the  food,  or  retention  of  the  latter 
within  the  stomach  until  it  is  stagnant,  and  causes  irritation  after  it 
passes  the  pylorus. 

The  etiologic  factors  of  the  secondary-  form  of  dyspepsia  just 
enumerated  require  no  further  elucidation,  since  the  effect  of  all  in 
producing  bowel  disturbance  has  been  fully  discussed  under  the  cap- 
tion of  Gastrogenic  Diarrheas.  The  part  played  in  primary  dyspepsia 
intestinalis  by  diseases  and  obstructions  of  the  liver,  pancreas,  and 
their  ducts,  whereby  too  little  or  too  much  of  the  juices  from  these 
organs  reach  the  intestine,  has  also  received  due  consideration  when 
outlining  the  etiology,  symptomatology,  diagnosis,  and  treatment  of 
pancreatic,  biliary,  fatty,  and  alcoholic  diarrheas  and  when  discussing 
the  physiology  of  digestion. 

Functional  and  organic  diseases  which  niiiiiniizc  or  increase  the 
gastric,  pancreatic,  or  biliary  fluids  or  alter  their  relation  to  each  other 


SYMPTOMS 


133 


constitute  the  most  frequent  and  perhaps  persistent  causes  of  entero- 
genic  dyspeptic  cHarrhea.  The  fact  should  not  be  overlooked  that  it 
may  result  from  an  abdominal  or  decreased  intestinal  secretion  result- 
ing from  nervous  disturbance  to  the  intestinal  mechanism,  impaired 
circulation,  anemia,  pathologic  changes  in  the  mucosa,  or  through  a 
lowered  resistance  and  undue  multiplication  of  pathogenic  bacteria 
and  their  toxins,  normal  inhabitants  and  products  of  the  bowel,  or 
those  which  reacli  it  through  tlie  food. 

Bacteria,  through  their  augmentation  of  the  fermentative  and 
putrefactixe  processes,  are  sometimes  responsible  for  intestinal  dys- 
pepsia and  diarrhea  through  their  abnormal  multiplication  and 
activity  within  the  bowel,  when  there  is  a  lowered  resistance  (particu- 
larly in  neurasthenic,  anemic,  and  tubercular  subjects)  on  the  part 
of  the  patient,  and  when  certain  forms  of  pathogenic  bacteria  are 
introduced  into  the  bowel  by  means  of  diseased  water  and  food. 

The  author  will  simply  state  here  that  this  form  of  indigestion 
may  occur  where  too  much  of  one  and  too  little  of  another  kind  of 
food  is  consumed;  the  fermentative  juices  are  unequally  balanced;  or 
the  subject  has  an  idiosyncrasy  to  certain  articles  of  diet. 

Persons  who  consume  an  excessive  amount  of  protein  suffer  less 
frequently  and  severely  from  enterogenic  dyspeptic  diarrhea  than 
those  who  are  indiscrete  as  to  the  quantity  of  fats  and  carbohydrates 
that  they  consume,  because,  after  all,  the  loose  movements  in  this 
class  of  cases  are  due  principally  to  the  irritating  effect  of  the  organic 
acids  (lactic,  acetic,  butyric,  and  gases  arising  from  the  bacterial 
decomposition  of  the  carbohydrates  and  fats)  within  the  bowel,  which 
are  present  in  undue  and  harmful  amounts  when  the  last-named  food 
products  dominate  the  diet,  or  their  digesting  ferments  are  diminished 
in  quantity,  or  are  prevented  by  obstruction  from  reaching  the  in- 
testinal canal. 

Duodenal  ulcers  are  occasionally  causative  factors  in  enterogenic 
diarrhea,  because,  through  the  irritation  and  reflex  disturbances  ex- 
cited by  them,  peristalsis  is  augmented,  the  intestinal  secretions 
are  increased,  and  food  is  rushed  through  the  small  intestine  into  the 
colon  before  digestion  has  taken  place,  and,  in  consequence,  rem- 
nants of  the  food  elements  appear  macroscopically  in  the  stools. 
The  lesions  occur  most  frequently  in  men,  and  may  be  secondary  to 
extensive  burns  or  mesenteric  embolism  with  digestion  of  the  infarct, 
or  they  may  be  induced  by  trauma  or  chronic  hyperacidity  (HCl). 
The  characteristic  manifestations  of  duodenal  ulcers  are  indigestion 
and  vomiting  after  meals,  severe  cramp-like  pains  in  the  right 
hypochondriac  region  several  hours  after  eating,  and  blood  in  the 
stools. 

The  symptoms  of  enterogenic  dyspepsia  vary  and  are  modified 
in  accordance  with  the  degree  of  complicating  gastric  disturbance 
when  present,  type  of  intestinal  indigestion  inciting  the  trouble,  the 
part  played  by  gastro-intestinal  catarrh,  and,  finally,  by  the  general 
condition  of  the  patient. 


134  ENTEROGENIC    DIARRHEA 

When  the  stomach  is  involved,  anorexia,  sometimes  acid  eructa- 
tions, nausea,  and  vomiting  are  present,  and  the  patient  complains 
of  fulness  and  pain  in  the  region  of  the  epigastrium.  The  intestinal 
manifestations  vary  greatly  in  different  cases,  but  loose  movements, 
accompanied  by  distention,  borborygmi,  flatus,  abdominal  discom- 
fort and  pain,  are  always  a  pronounced  feature,  and  it  might  not  be 
inappropriate  to  designate  this  condition  as  a  dyspeptic  acid  diarrhea, 
because  in  most  instances  the  excessive  irritation  to  the  bowel,  in- 
creased peristalsis,  and  secretion  are  largely  due  to  abnormal  acidity 
of  the  intestinal  contents,  on  account  of  which  the  chyme  is  first  hurried 
through  the  small  intestine  before  digestion  takes  place,  and  then 
through  the  colon  with  such  haste  that  absorption  is  impossible. 
The  stools  under  these  circumstances  are  acid,  frequent,  fluid,  and 
cause  considerable  burning  and  tenesmus  of  the  rectum  and  more  or 
less  irritation  to  the  perianal  skin  once  the  attack  is  on,  but  such 
stools  come  from  the  upper  intestine,  and  in  the  beginning  are  pre- 
ceded by  one  or  two  semisolid  or  formed  movements,  composed  of 
feces  which  had  previously  collected  in  the  colon  or  rectum.  The 
abnormal  evacuations  are  frequently  gelatinous  in  consistence  owing 
to  the  presence  of  a  large  amount  of  mucus,  under  which  circumstances 
it  is  difficult  to  determine  whether  it  arises  from  dyspepsia  or  intes- 
tinal catarrh.  In  the  latter,  however,  epithelial  and  isolated  round 
cells  are  more  noticeable,  while  in  the  former  the  mucus  is  apt  to  be 
bile  stained. 

In  underfed  children,  with  an  idiosyncrasy  to  carbohydrates 
owing  to  the  predominance  of  fat,  the  stools  are  of  a  light  or  grayish 
color,  the  Bacillus  bifidus  is  present  in  considerable  numbers,  and 
the  amount  of  indican  and  phenol  in  the  urine  is  greatly  exaggerated. 

Schmidt  and  Strasburger  have  called  attention  to  what  they 
designate  "intestinal  fermentation  dyspepsia,"  which  closely  resem- 
bles the  jejunal  type  of  diarrhea  just  discussed,  which  they  believe  is 
dependent  upon  insufficient  digestion  of  starch  as  revealed  by  the 
fermentation  test  and  stool  analysis  following  a  special  diet. 

Nothnagel  has  tersely  summed  up  their  views  as  follows:  "The 
subjective  symptoms  are  rather  vague,  but  abdominal  pains,  chiefly 
in  the  umbilical  region,  fatigue,  and  discomfort  are  the  most  promi- 
nent. Abdomen  frequently  symmetrically  distended,  usually  tender 
on  palpation,  either  universally  or  limited  to  umbilical  region  or  to 
the  left  of  it.  Examination  of  stomach  rarely  gives  pathologic  indi- 
cations. Feces  (after  test-meal)  evacuated  somewhat  more  fre- 
quently, but  no  actual  diarrhea.  Stools  are  often  foamy,  light  yel- 
low, acid,  with  the  odor  of  butyric  acid.  Other  indications  usually 
absent,  particularly  noticeable  being  the  lack  of  mucus,  and  often  of 
starch,  but  after  ingestion  of  potato  there  occur  plentiful  empty 
potato  cells."  These  authorities  believe  that  cases  may  be  of  neurotic 
origin,  the  result  of  catarrh  or  purely  functional  in  character. 

The  diagnosis  of  dyspeptic  diarrhea  is  not  always  easy,  and  must 
be  distinguished  from  catarrhal  loose  movements.     In  some  instances 


TREATMENT 


135 


the  history  will  throw  light  upon  the  case,  but  usually  reliance  is  to 
be  placed  upon  gastric  and  fecal  analysis  following  test-meals  to 
determine  the  part,  if  any,  played  by  unbalanced  gastric,  biliary,  or 
pancreatic  juices,  and  also  if  there  is  imperfect  protein,  carbohydrate, 
or  fat  digestion.  The  presence  of  mucus,  pus,  or  blood,  when  discov- 
ered, indicates  catarrhal  organic  changes. 

From  what  has  been  said,  acid  and  gelatinous  evacuations  contain- 
ing considerable  bile-stained  mucus  without  epithelial  or  round  cells 
indicate  the  jejunal  character  of  the  diarrhea. 

Anders^  groups  the  differentiating  features  between  duodenal 
and  gastric  ulcers  as  follows;  in  other  respects  the  manifestations  of 
the  two  conditions  are  about  the  same: 


DUODENAL    ULCER. 

Usually  occurs  between  twenty  and  forty 
years,  except  when  due  to  external  burns. 

IMales  are  more  frequent  sufferers  than 
females  in  the  proportion  of  10  to  i. 

Onset  marked  by  intestinal  hemorrhage, 
which  maj-  recur  at  internals  of  varying 
duration. 

The  melena  may  be  preceded  or  accom- 
panied by  hematemesis,  though  not  gener- 
aUy. 

Blood  in  the  discharges  often  is  bright  red, 
profuse,  but  not  so  marked  as  in  gastror- 
rhagia;  sometimes  dark  and  tarry  from  the 
action  of  acid  chyme  when  shght. 

Pain,  due  to  acid,  may  come  on  late,  two  to 
four  hours  after  meals;  more  often  absent. 
It  is  localized  a  little  above  and  to  the 
right  of  the  umbilicus.  Pain  relieved  by 
eating,  owing  to  absorption  of  acid  and 
closure  of  the  pylorus. 

Gastric  crises  occur  without  reference  to 
time  of  taking  food. 

Vomiting  inconstant  without  relation  to 
ingestion  of  food  and  affords  no  relief. 

Jaundice  occasionally  present  from  occlusion 
of  bile-duct. 

No  marked  improvement  after  diet  has  been 
regulated. 

Dorsal  pain-point  absent. 


G.^STRIC   ULCER. 

Maj-  occur  at  any  age  after  childhctod. 

Females  are  the  chief  sufferers. 

Gastric  hemorrhage  often  occurs,  preceded 
by  other  gastric  symptoms,  as  a  rule. 

Blood  may  appear  in  the  stools,  usually 
after  hematemesis. 

The  blood  in  the  dejections  is  dark  and 
tarry  from  the  action  of  the  gastric 
juices. 

Pain,  paroxysmal,  greatly  influenced  by 
taking  food.  Pain  sharply  localized  in 
the  epigastric  region  about  2  inches 
below  the  ensiform  cartilage.  Usually 
pain  is  aggravated  by  taking  food. 

Gastric  crises  come  on  soon  after  taking 

food. 
Vomiting  more  common   (during  painful 

crisis)  and  affords  relief. 
Jaundice  absent. 

Usually  a  marked  improvement  follows 
regulation  of  diet. 

Pain-point  (tenth  to  twelfth  dorsal  ver- 
tebrae on  left  side)  usually  present. 


The  treatment  here  is  largely  dietary,  and  certain  types  of  food 
should  be  interdicted  or  liinited  and  others  increased,  according  as 
the  diet  is  improperly  balanced  and  one  variety  is  being  partaken  of 
in  amounts  larger  than  can  be  digested,  and  in  rare  instances,  where 
solids  cause  undue  irritation,  it  is  advisable  to  resort  to  a  liquid  diet 
until  later,  when  the  patient  can  take  care  of  solids. 

In   the   presence   of   fermentative  diarrhea  and   oft-repeated   gas 

distention,  vegetables  should  be  partaken  of  sparingly,  and  reliance 

should  be  placed   upon    eggs,  soups,  jellies,  gelatins,  gruels,  and  one 

of  the  lactic  acid  bacillus,  sour  milks,    such   as   koumyss,   matzoon, 

1  Practice  of  Medicine,  1910. 


136  ENTEROGENIC    DIARRHEA 

bacillac,  lactone,  buttermilk,  or  lactoform.  When  there  is  marked 
distress  from  gas  this  can  usually  be  relieved  by  having  the  patient 
take  I  or  2  drops  of  turpentine  on  lump  sugar,  three  times  daily, 
or  ginger,  peppermint,  lime-water,  or  one  of  the  carminative  teas 
may  answer  the  same  purpose. 

When  the  e\'acuations  are  foul,  and  result  from  putrefaction  or 
albuminous  decomposition,  this  is  best  corrected  by  gr.  ij  to  iij  (0.12- 
0.18)  of  calomel  in  broken  doses,  administered  weekly,  until  the 
stools  are  less  frequent  and  offensive,  using  in  the  intervals  salol, 
beta-naphthol,  resorcin,  guaiacol,  ichthyol,  nj  v  (0.30),  or  salicylic 
acid,  gr.  v  (0.30),  four  times  daily,  alone  or  in  combination  with  char- 
coal, chalk,  or  bismuth,  for  their  antiseptic  action  upon  the  putrid 
intestinal  contents. 

When  enterogenic  dyspeptic  diarrhea  cannot  be  controlled  in  the 
above  way,  the  desired  results  are  usually  obtainable  through  the 
administration  of  opium  or  morphin,  gr.  j  (0.015),  with  belladonna, 
gr.  I  (0.008),  when  there  are  cramps;  or  an  astringent,  as  ichthyol, 
tanniform,  tannalbin,  or  gallic  acid,  gr.  v  (0.30),  three  or  four  times 
daily,  which,  because  of  their  antidiarrheal  (astringent)  action 
decrease  the  number  and  fluidity  of  the  movements. 

When  dyspepsia  intestinalis  is  due  to  imperfect  starch  digestion, 
the  author  knows  of  no  more  effective  remedies  than  taka  diastase, 
gr.  V  (0.30),  at  mealtimes,  but  when  the  disturbance  is  due  to  the 
indigestion  of  meats  and  fats,  pancreatin,  gr.  v  (0.30),  is  indicated. 

Usually  acute  attacks  of  intestinal  indigestion  and  diarrhea  are 
controllable  by  the  methods  outlined,  but  when  the  condition  be- 
comes chronic  it  may  be  necessary  to  watch  the  diet  carefully  for  a 
considerable  time,  to  employ  antidiarrheal  remedies,  but  in  smaller 
doses  over  a  long  period,  and  to  direct  treatment  against  catarrh  of 
the  intestine  w^hich  arises  sooner  or  later. 

In  aggravated  cases  the  mucosa  of  the  colon  alw^ays  becomes 
inflamed  and  sometimes  erosions  or  ulcers  form,  and  in  neglected 
cases,  owing  to  the  part  played  by  a  mixed  infection,  they  may  rapidly 
increase  in  size,  indications  of  which  are  to  be  seen  in  the  presence  of 
considerable  pus,  blood,  and  mucus  in  the  stools.  The  astringent, 
sedative,  and  antiseptic  remedies  mentioned  have  a  favorable  action 
and  are  conducive  to  healing,  but  better  and  quicker  results  are  ob- 
tained when  the  large  intestine  is  irrigated  daily  with  a  normal  saline, 
weak  Carlsbad  salt,  ichthyol,  boric  acid  or  permanganate  of  potas- 
sium solution,  or  an  infusion  of  flaxseed  or  oak  bark. 

The  treatment  outlined  here  relates  principally  to  jejiiuaJ  diarrhea, 
which  represents  the  most  common  form  of  enterogenic  loose  move- 
ments. The  therapeutic  measures  practised  for  the  relief  of  this 
type  of  diarrhea,  arising  from  gastric,  hepatic,  and  pancreatic  dis- 
turbances, have  been  omitted  here  since  they  have  received  separate 
and  full  consideration  elsewhere. 

Duodenal  (peptic,  etc.)  ulcers  require  about  the  same  treatment 
as  gastric  ulcers,  the  therapeutic  measures  for  the  relief  of  which  have 


TREATMENT  1 37 

been  fully  discussed  in  the  preceding  chapter.  The  treatment  indi- 
cated in  these  cases  briefly  summed  up  consist  (a)  in  having  the 
patient  rest  quietly  in  bed  for  several  weeks;  (&)  restricting  his  nour- 
ishment to  fluid  foods  and  nutritive  enemata;  (c)  prescribing  opiates, 
astringents,  antiseptics,  alkalies,  and  tonics  to  relieve  pain,  diminish 
the  evacuations,  minimize  fermentation,  heal  the  ulcers,  lessen  the 
acidity  of  the  chyme,  and  improve  the  patient's  general  condition; 
and  (d)  when  these  and  other  therapeutic  measures  fail,  gastro-enter- 
ostomy,  resection,  or  a  plastic  operation  should  be  resorted  to  to  secure 
the  necessary  relief. 


CHAPTER  XII 

NEUROGENIC    DIARRHEA    (FUNCTIONAL,    POSTPRANDIAL 
DIARRHEA,   NOCTURNAL  DIARRHEA) 

PSYCHIC    DISEASES   AND   INJURIES   OF  THE    NERVOUS  SYSTEM,  RE- 
FLEX DISTURBANCES,  AFFECTIONS  OF  THE  THYROID  GLAND 

Neurotic  individuals  frequently  suffer  from  irregular  bowel 
movements.  Most  of  them  are  troubled  with  constipation,  but  not 
a  few  complain  bitterly  of  periodic  attacks  of  diarrhea. 

Nervous  diarrhea  may  be  encountered  in  persons  suffering  from 
organic  nervous  diseases,  those  who  are  nervous  as  the  result  of  other 
ailments,  and  in  normal  high-strung  or  sensitive  indi\'iduals,  follow- 
ing emotional  disturbances,  frequent  movements  suddenly  supervene. 

Seldom  in  this  class  of  individuals  constipation  or  obstipation 
prevails  for  a  considerable  time,  to  give  way  alternately  or  continu- 
ously to  diarrhea,  when  the  nervous  mechanism  is  interfered  with 
by  way  of  the  brain,  intestinal  nerve-endings,  or  is  affected  through 
reflex  impulses. 

This  type  of  increased  evacuations  occurs  slightly  more  frequent 
in  men  than  women  and  at  any  age,  but  is  met  with  most  often  be- 
tween twenty-five  and  fifty,  or  the  time  of  life  when  the  patient 
undergoes  his  greatest  mental  and  physical  strain,  is  apt  to  indulge 
in  excesses  or  suffer  from  a  sedentary  occupation  and  confinement  in 
poorly  lighted  and  ventilated  rooms,  which  cause  suboxidation,  a 
forerunner  of  nervous  disturbances. 

Nervous  diarrhea  is  characterized  by  its  sudden  onset,  periodicity, 
rapid  succession  of  evacuations,  extreme  fluidity  of  the  movements, 
with  exception  of  the  first,  which  may  be  semisolid  or  firm,  and  is  most 
often  encountered  in  emotional,  neurasthenic,  or  hysteric  subjects. 
It  is  generally  conceded  that  the  mo\ements  in  these  cases  are  caused 
by  either  hyperperistahis,  augmented  glandular  secretion,  acceler- 
ated transudation  of  fluid  into  the  bowel,  or  hypo-absorption,  one  or 
all  resulting  from  abnormal  impulses  originating  in  the  cerebrum, 
general  nervous  system,  or  more  directly  in  the  intestinal  nerve 
plexuses. 

Through  reflex  vasomotor  phenomena  originated  by  nervous  in- 
fluences, according  to  Lemoine,  the  intestinal  vessels  become  dilated, 
which  favors  transudation  of  fluid  into  the  intestine,  causing  the 
diarrheal  crises. 

It  is  customary  to  consider  as  nervous  nearly  all  diarrheas  which 
cannot  be  attributed  to  errors  in  diet  or  lesions  of  the  gastro-intestinal 
tract,  but  undoubtedly  many  mistakes  have  followed  this  practice. 
138 


PSYCHIC    DISEASES    AND    IXJUKIIvS    OF    THE    NERVOUS    SYSTEM       1 39 

The  author  beHeves,  with  Kleiner,  that  in  the  presence  of  true  chronic 
diarrhea,  which  persists  without  interruption  and  merely  varies  in 
severity,  that  a  diagnosis  of  nervous  diarrhea  should  he  made  with 
great  caution,  and,  while  he  does  not  doubt  the  existence  of  chronic 
diarrhea  upon  a  nervous  and  psychopathic  basis  in  exceptional  cases, 
he  is  of  the  opinion  that  frequent  movements  excited  by  other  con- 
ditions are  often  ascribed  to  nervous  diarrhea. 

Undoubtedly,  the  intestinal  nerve  apparatus  within  the  gut  wall 
directly  influences  motility,  secretion,  and  absorption,  and  the  func- 
tionating power  of  the  gut  is  stimulated  or  inhibted  by  disease  within 
it  affecting  the  ner\e-endings,  and  constipation  (jr  diarrhea  is  the 
result  in  accordance  as  the  impulses  change. 

It  is  equally  true  that  the  sole  control  of  the  various  functionating 
powers  of  the  intestine  is  not  confined  within  it,  because  there  is  suffi- 
cient evidence  to  prove  (as  will  be  shown  later)  that  certain  organic 
diseases  of  the  nerve  mechanism  in  near  and  distant  parts  may  lead 
to  reflex  disturbances  which  are  capable  of  increasing  or  decreas- 
ing the  evacuations,  and  that  regularity  of  the  movements  is  at  times 
modified  by  psychic  impulses. 

Owing  to  the  correlation  which  exists  between  the  brain,  cord, 
vagus  nerve,  the  sympathetic  system,  and  intestinal  nervous  mechan- 
ism, impulses  are  incapable  of  transmission  in  either  direction,  for  or 
against  the  welfare  of  the  indi\'idual,  according  to  the  location  of  the 
lesion  or  direction  from  which  the  disturbing  or  healthful  influence 
C(mies.  With  this  knowledge,  it  is  easy  to  understand  that  intes- 
tinal neurosis,  such  as  diarrhea,  may  occur  but  once,  periodically,  or 
remain  permanently,  in  different  cases,  in  accordance  with  the  nature 
and  duration  of  the  pathologic  lesion  or  exciting  impulse  back  of  it. 

Psychic  nervous  diarrhea  may  be  brought  on  by  profound  emotions 
of  all  kinds,  such  as  sudden  fright,  prolonged  terror,  anxiety,  anger, 
public  speaking,  trying  a  case  before  judge  or  jury,  acting  a  play  for 
the  first  time,  taking  an  examination,  being  grilled  upon  the  witness 
stand,  excitement  attending  a  journey  or  being  aware  of  the  fact 
that  there  will  be  no  opportunit\-  to  evacuate  the  bowel  for  a  given 
time. 

The  atithor  has  treated  patients  from  one  or  all  of  the  above  types 
of  psychic  diarrhea.  One,  a  man  fifty  years  of  age,  who  had  been  a 
comic  opera  singer  for  thirty  years,  invariably  suffered  from  griping 
pains,  faintness,  and  diarrhea  on  each  first  night,  during  which  he 
passed  a  number  of  watery  evacuations,  and  sufl^ered  great  mental 
agony  while  playing,  because  he  did  not  know  whether  an  accident 
would  occur  or  not.  Another  case  previously  reported  was  that  of 
a  minister  whose  movements  were  normal  in  number  and  consistence 
except  on  Sunday,  when  they  became  fluid  and  frequent,  owing  to  the 
mental  strain  under  which  he  labored  in  delivering  his  sermon  and  the 
knowledge  that  he  could  not  go  to  the  toilet  until  after  it  was  finished. 

The  author  was  informed  by  the  foreman  of  a  gang  of  Italian 
laborers  that  several  of  his  men  defecated  in  their  clothing  simul- 


140  NEUROGENIC    DIARRHEA 

taneously  with  the  accidental  explosion  of  an  enormous  amount  of 
dynamite,  and  that  the  shock  affected  one  of  them  to  the  extent  that 
he  suffered  from  watery  movements  for  several  days  thereafter. 

The  author  has  known  of  other  instances  where  diarrhea  resulted 
from  fright  or  worry,  one  of  which  was  that  of  a  lawyer  who  inva- 
riably suffered  from  diarrhea  each  time  he  tried  a  case.  He  has  also 
treated  a  man,  a  highly  sensitive  indi\idual,  whose  mucosa  appeared 
to  be  sound,  yet  a  diarrheic  condition  could  be  brought  about  by 
applying  the  electric  current  or  the  vibrator  to  the  abdomen,  by  the 
introduction  of  the  proctoscope,  or  by  making  topical  application  to 
the  intestinal  mucosa. 

Cases  of  this  kind  have  also  been  studied  in  individuals  who  were 
nursing  friends  or  relatives  fatally  ill,  whenever  frequent  movements 
were  incidental  to  a  depressed  or  fatigued  mental  state,  anxiety,  or 
fear  that  they  would  contract  the  disease;  others  have  been  observed 
where  patients  afflicted  with  constipation  or  other  ailments  became 
worried  over  their  condition  and  diarrhea  ensued,  which  increased 
their  fear,  and  this,  in  turn,  proportionately  increased  the  frequency 
of  the  evacuations.  When  it  was  explained  to  them  that  their  afflic- 
tion was  not  serious,  and  that  recovery  would  shortly  follow,  the 
movements  became  less  frequent  as  their  mental  state  improved,  but 
in  the  case  of  one  woman,  whose  fear  could  not  be  allayed,  diarrhea 
became  chronic,  and  proved  to  be  more  distressing  than  her  original 
ailment.  Numerous  instances  have  been  related  or  published  where 
persons,  particularly  young  W'Omen,  have  suddenly  been  attacked  with 
nervous  diarrhea  when  they  were  in  the  presence  of  company  and  in 
a  restaurant,  theater,  or  strange  house,  or  taking  a  long  automobile 
trip,  and  knew  that  there  would  be  no  opportunity-  to  go  to  the  toilet 
for  a  considerable  time. 

The  author  has  also  treated  patients  who  suffered  from  colitis, 
cancer,  etc.,  wherein  the  stools  were  made  more  frequent  by  suggest- 
ing to  them  that  they  needed  an  appendicostomy,  cecostomy,  colos- 
tomy, or  intestinal  resection  or  other  operation,  and  Muszkats  has 
reported  a  case  of  constipation  wuth  vasomotor  instability  where  the 
patient  voided  from  i  to  6  oz.  of  thin  mucus  every  time  he  became 
angry,  the  attack  being  devoid  of  pain,  and  the  discharge  contained 
neither  shreds  nor  casts,  in  contradistinction  to  the  evacuations  of 
membranous  colitis.  Grasset,  under  the  caption  "psychosplanchnic" 
or  cerebrovisceral  neuropathy,  describes  what  he  considers  a  new  form 
of  gastro-intestinal  neurosis,  which  is  frequently  accompanied  by 
nervous  dyspepsia,  disturbance  of  intestinal  secretions,  obstipation 
often  alternating  with  diarrhea,  meteorism,  and  discharges  of  mucous 
collections  containing  shreds  or  casts,  complicated  by  occasional  heart 
and  respiratory  disturbances. 

This  condition  ma>'  obtain  in  perfectly  healthy  indi\'iduals  under 
the  above  and  other  forms  of  powerful  psychic  impression,  but  is 
most  often  encountered  in  persons  who  suffer  from  neurasthenia, 
hysteria,   migraine,  goiter,  or  traumatic  neuroses.     Ordinarily,  con- 


PSYCHIC    DISEASES    AND    INJURIES    OF    THE    NERVOUS    SYSTEM       I4I 

stipation  prevails  in  the  presence  of  the  more  serious  functional  and 
organic  diseases  of  the  ncr\T)us  system;  sometimes,  however,  this 
condition  alternates  wiili  diarrhea  or  gives  way  entirely  to  it,  in 
connection  with  or  independent  of  psychic  impulses. 

Frequent  ev^acuations  in  neuropathic  individuals  are  attributable 
mainly  to  accelerated  peristalsis  and  transudation  into  the  gut  of 
rtuid.  Owing  to  peristaltic  activity  the  stomach  discharges  improp- 
erly prepared  food  into  the  disquieted  small  bowel,  and  the  undigested 
food  remnants  are  a  source  of  irritation  and  aggravate  the  condition 
through  their  tendency  to  stimulate  the  glands  to  oversecretion  and 
the  vermicular  movements  to  greater  activity.  This  irritation  con- 
tinues in  the  large  bowel  where  peristalsis  is  already  marked,  and 
transudation  is  active  through  the  instigating  nervous  influence. 
Since  the  serous  fluid  accimiulates  rapidly,  and  the  segmental  contrac- 
tions of  the  colon  are  strong  and  frequent,  it  necessarily  follows  that 
the  evacuations  must  be  watery  and  follow  each  other  in  ciuick  suc- 
cession. 

This  condition  is  easily  distinguishable  from  peristaltic  unrest, 
where  intestinal  activity  is  limited  principally  to  the  small  gut,  and 
from  membranous  colitis,  so  frequently  encountered  in  nervous  per- 
sons, because  of  the  small  amount  of  mucus  in  the  stools  and  the 
total  absence  of  shreds  and  casts. 

The  frequency,  duration,  and  severity  of  the  attacks  are  pro- 
portionate to  the  nervous  state  of  the  patient  and  the  varying  mental 
condition,  the  time  required  to  relieve  his  disciuieted  state,  and  the 
frequency  of  his  relapses.  In  neglected  and  poorly  treated  cases, 
where  nervous  diarrhea  has  existed  for  a  considerable  time,  the  patient 
is  likely  to  contract  chronic  diarrhea  as  the  result  of  the  nervous  dis- 
turbance, and  the  irritable  and  inflamed  mucosa  inducing  the  passage 
oxer  it  of  undigested  food  remnants,  acrid  discharges,  straining,  and 
prolonged  trauma  to  the  intestine  caused  by  peristalsis. 

Highly  strung  and  nervous  individuals  who  gormandize,  eat 
hastily  and  generously  of  spiced  foods,  often  at  irregular  hours  or 
when  fatigued,  and  consume  an  excess  of  alcoholic  beverages,  are 
prone  to  nervous  diarrhea,  because  these  habits  lead  to  an  irritable 
state  of  the  intestinal  nerve-endings  which  al)n(jnnall\'  respond  to 
psychic  and  other  stimuli. 

There  is  a  peculiar  form  of  nervous  diarrhea  which  occurs  during 
or  immediately  following  the  consumption  of  food.  In  some  instances 
particular  articles  of  diet  will  cause  it,  but  in  others  frequent  evacua- 
tions are  incited  by  whatever  is  eaten.  The  attacks  may  follow  any 
meal,  but  usually  occur  after  lunch.  Sharp  pain  is  felt  in  the  epi- 
gastrium almost  as  soon  as  the  food  has  been  swallowed;  it  continues 
and  then  becomes  more  severe,  and  gradually  works  downward  until 
it  becomes  agonizing,  and  is  located  in  the  lower  and  central  part  of 
the  abdomen.  By  this  time  the  patient  is  pale,  weak,  breaks  out  in  a 
cold  perspiration,  suffers  from  gas  distention  and  borborygmus  and 
an  imperative  desire  to  empty  the  bowel,  the  straining  incident  to 


142  NEUROGENIC    DIARRHEA 

which  increases  his  suffering,  Avhich  continues  until  he  has  two  or 
three  evacuations  that  bring  inexpressible  reHef,  excepting  intestinal 
soreness.  The  stools  in  this  class  of  cases  are  watery,  composed  largely 
of  bile  and  fluid  feces.  No  doubt  in  some  instances  excessive  biliary 
secretion  is  responsible  for  the  trouble,  but  the  author  has  treated 
patients  where  the  crises  were  evidently  influenced  by  organic  neu- 
rosis and  powerful  psychic  emotions.  This  and  the  type  of  diarrhea 
which  follows  immediately  after  eating  is  termed  "prandial"  by  Linos- 
sier. 

Reflex  disturbances  are  at  times  partially  or  solely  responsible  for 
attacks  of  nervous  diarrhea,  and  the  stimulating  impulses  may  origi- 
nate in  the  brain,  intestine,  or  the  peripheral  parts.  Occasionally, 
perfectly  healthy  individuals  are  attacked  with  diarrhea  wherein 
the  stools  are  frequent,  watery,  and  occur  in  rapid  succession  follow- 
ing exposure  to  cold,  sitting  on  damp  steps  or  the  ground,  swimming  in 
cold  water,  or  getting  wet  feet,  a  type  of  disturbance  which  has  been 
classified  as  nervous  diarrhea,  since  the  trouble  evidently  resulted 
from  stimulation  of  the  peripheral  nerves. 

Diarrhea  is  frequently  associated  with  or  caused  by  disease  of  the 
male  and  female  genital  organs,  and  results  through  reflex  disturb- 
ance, because  the  crises  occur  at  the  times  when  the  patient  suffers 
most  and  is  worried  owing  to  aggravation  of  his  local  condition.  This 
is  particularly  noticeable  during  the  menstrual  period  in  women,  and 
especially  those  who  suffer  from  dysmenorrhea,  uterine  catarrh,  and 
displacements,  extensive  complete  perineal  tears,  and  cervical  ulcera- 
tion. The  author  has  treated  nervous  men  suffering  from  vesical, 
prostatic,  and  deep  urethral  trouble,  who  sought  relief  from  diarrhea 
which  accompanied  exacerbation  of  their  local  condition,  but  in  most 
instances  they  really  suffered  from  tenesmus  and  not  nervous  diar- 
rhea, as  was  evidenced  by  the  fact  that  the  stools  were  semisolid 
or  firm,  and  not  watery,  as  one  would  expect. 

Certain  diarrheas  which  accompany  or  follow  the  subsidence  of 
perityphlitis,  pericolitis,  perisigmoiditis,  and  periproctitis,  abdominal 
and  pelvic  inflammations,  or  peritonitis  are  classed  as  nervous,  be- 
cause they  cannot  be  explained  except  through  nerve  irritation. 
The  same  may  be  said  regarding  pelvic  and  perirectal  abscesses  ac- 
companied by  frequent  movements,  with  the  possibility  here  that  the 
excretion  of  toxins  into  the  intestine  is  the  exciting  cause.  The 
author  has  relieved  patients  who  for  a  number  of  years  had  suffered 
from  chronic  diarrhea  by  the  removal  of  a  coccyx  which  was  deviated 
anteriorly  and  irritated  the  rectum,  or  was  fractured  and  caused 
pressure  upon  its  nerves.  He  has  known  tumors  to  cause  diarrhea  by 
pressing  upon  the  sympathetic  plexuses  in  the  pelvis  or  compressing 
nerves  at  their  exit  from  the  cord. 

He  has  also  studied  patients  who  suffered  from  a  sensitive  or 
so-called  hysteric  rectum,  in  whom  an  attack  of  diarrhea  could  be 
immediately  brought  on  through  the  introduction  of  a  proctoscope  or 
application  of  topical  medication  to  the  mucosa. 


PSYCHIC    DISEASES    AND    INJURIES    OF    THE    NERVOUS    SYSTEM       1 43 

Both  adults  and  children  affected  with  extensive  invagination  and 
procidentia  recti  have  been  observed  to  suffer  from  diarrhea  inde- 
pendent of  the  fact  that  the  bowel  was  healthy.  The  frequent  move- 
ments in  these  cases  were  probably  incited  by  pulling  upon  the  mesen- 
teric nerxes.  At  any  rate,  the  diarrhea  was  cured  simultaneously 
with  correction  of  the  procidentia. 

Large  and  small  inflammatory  and  ulcerative  lesions  of  all  kinds 
located  in  the  rectum  and  other  part  of  the  intestine  are  capable  of 
inducing  frequent  evacuations  through  exposure  of  the  terminal 
nerve-endings  to  the  irritating  intestinal  bacteria,  hard  fecal  masses, 
and  other  contents  of  the  colon. 

Extremely  ner\-ous  individuals  and  those  who  worry,  become 
angered  or  are  affected  by  other  powerful  psychic  emotions,  or  who 
have  intestinal  disease,  suffer  more  frequently  and  intensely  from 
diarrhea  than  normal  persons.  In  such  cases  the  diarrhea  should 
be  attributed  both  to  nervous  influences  and  the  pathologic  state  of 
the  bowel. 

Influenza  is  frequently  complicated  by  diarrhea,  which  in  some 
instances  is  attributable  to  the  catarrhal  state  of  the  bowel,  and  in 
others  to  influenza  toxins  which  reach  the  intestinal  nerves  through 
the  circulation.  Diarrhea  and  loose  or  uncontrollable  evacuations 
are  at  times  associated  with  or  complicate  organic  and  functional  dis- 
eases of  the  nervous  system,  although  constipation  is  more  often  present 
under  these  circumstances. 

Diarrhea  complicating  epilepsy  usualK-  occurs  during  the  crises, 
which  are  generally  preceded  by  a  rise  in  temperature  and  restless- 
ness on  the  part  of  the  patient. 

Intestinal  auto-intoxication  may  profoundly  influence  frequency 
of  the  evacuation,  both  in  constipation,  where  the  toxins  are  long 
retained,  and  in  diarrhea,  where  the  fluidity  of  the  stools  and  erosions 
of  the  mucosa  favor  quick  entrance  of  the  poison  into  the  circulation. 
The  degree  to  which  the  patient  is  being  poisoned  under  these  cir- 
cumstances is  indicated  through  the  effects  of  the  toxins  upon  the 
general  nervous  system,  as  manifested  by  the  character  and  frequency 
of  the  attacks  and  by  the  amount  of  skatol  and  indican  discoverable 
in  the  urine.  Rodiet  believes  that  the  crises  are  the  result  of  the 
action  of  these  substances  upon  a  predisposed  organism. 

In  tahes  dorsal  is  the  usual  constipated  state  may  obtain  through- 
out, alternate  with  diarrhea,  or  in  exceptional  instances  the  latter 
may  prevail  during  intestinal  crises,  and  be  accompanied  by  ab- 
dominal pain,  rectal  tenesmus,  and  frequent  discharge  of  exhausting, 
water\'  evacuations.  Some  of  these  attacks  are  traceable  to  psychic 
impulses,  and  others  to  constipation,  fecal  impaction,  and  auto-intoxi- 
cation, but  in  many  instances  the  etiolog\-  of  the  diarrhea  remains 
obscure. 

Tabetic  diarrhea  may  be  intermittent  or  continuous,  and  the 
former,  which  begins  in  the  pre-ataxic  stage,  is  severe  and  the  move- 
ments occur  involuntarily  unless  the  bowel  is  instantaneously  emptied, 


144  NEUROGENIC    DIARRHEA 

and  while  the  attack  lasts  control  of  the  evacuations  is  nearly  if  not 
entirely  impossible. 

Neurogenic  diarrhea  is  also  a  common  manifestation  of  neuras- 
thenia and  hysteria  in  the  absence  of  intestinal  lesions,  attributable 
probably  to  an  abnormal  mental  condition  and  irritability  of  the 
general  nervous  system. 

Peculiarly  enough,  this  complaint  often  complicates  the  terminal 
state  of  migraine,  but  no  one  as  yet  has  offered  a  satisfactory  ex- 
planation of  the  relationshij)  unless  it  be  accounted  for  in  one  of  the 
above-mentioned  ways. 

The  author  has  observed  several  patients  who  suffered  from 
tenesmus  and  abnormally  frequent  semisolid  or  liquid  movements 
caused  by  hypersensitive  areas  located  in  the  sigmoid  flexure  and, 
rectum,  which  independently  or  when  stimulated  by  the  presence  of 
feces  incited  an  imperative  desire  to  stool,  a  sensation  which  con- 
tinued until  several  movements  occurred  in  quick  succession  or 
relief  was  obtained  through  medication.  He  has  also  treated  a  number 
of  nervous  children  and  occasionally  adults  who  from  infancy  had 
been  troubled  with  loose  movements,  which  were  involuntarily  dis- 
charged as  was  the  urine,  and  in  these  cases  the  diarrhea  or,  rather, 
muscular  paralysis  which  permitted  the  urine  and  feces  to  escape 
without  warning,  was  traceable  to  injury  or  disease  in  the  spinal 
nerve-centers  which  control  the  musculature  of  the  rectum  and 
bladder. 

Symptoms. — The  manifestations  of  neurogenic  diarrhea  differ  from 
those  of  other  causes  principally  in  the  following  ways:  It  occurs  in 
psychically  disturbed  or  highly  strung  persons  or  those  afflicted  with 
functional  or  organic  nervous  disease.  The  attacks  are  periodic, 
of  sudden  onset,  the  movements  are  very  thin  and  watery,  occur  in 
rapid  succession  without  inducing  tenesmus,  take  place  usually  in  the 
early  morning,  may  vary  anywhere  from  five  to  twenty  daily,  and 
contain  but  little  mucus  and  no  pus  or  blood.  The  frequency, 
severity,  and  duration  of  the  crises  are  governed  by  the  type  of  emo- 
tion to  which  the  patient  is  subjected,  continued  irritation  to  local 
nerves  or  general  nerve  mechanism,  overactive  exercise,  fatigue,  and 
other  conditions  which  influence  the  nervous  organism. 

Diarrheal  crises  of  nervous  origin  are  frequently  accompanied  by 
dizziness,  cerebral  congestion,  depressed  feeling,  difficult  or  rapid 
breathing,  uneasiness  about  the  heart,  and  sensations  of  heat  and 
cold,  loss  of  appetite,  indigestion,  abdominal  weakness,  intestinal 
unrest,  borborygmus,  occasionally  tympanites,  epigastric  and  lower 
abdominal  pain,  and  in  the  type  of  nervous  diarrhea  which  imme- 
diately follows  the  taking  of  food,  an  irresistible  desire  to  stool. 

In  instances  where  gastric  irritation  predominates,  vomiting  is  an 
annoying  feature,  and  the  substance  evacuated  may  be  undigested 
food  or  consist  of  mucus  and  bile.  Some  of  the  author's  patients 
complained  but  slightly  of  intestinal  disturbances,  but  in  others, 
although  there  was  no  determinable  lesion  of  the  mucosa,  passage  of 


DIAC.XOSIS  145 

the  {()()(]  in  some  instances  excited  colic  dnd  enterospasm  or  pronounced 
peristalsis,  which  left  the  bowel  sore. 

When  these  patients  suffer  continually  from  pain  and  diarrhea  per- 
sists regularly  for  a  long  time,  there  are  localized  tender  spots  along 
the  intestine,  the  stools  contain  a  considerable  amount  of  pus,  blood, 
and  mucus,  and  there  is  much  pain  preceding  and  tenesmus  during 
defecation,  the  diarrhea  may  be  attributed  both  to  nerxous  disturb- 
ances and  enteritis  or  enterocolitis. 

Diagnosis. —  In  typic  cases,  where  the  above-mentioned  char- 
acteristic symptoms  are  present,  nervous  diarrhea  may  be  recognized 
with  comparative  ease,  but  in  less  marked  instances,  particularly  in 
nervous  individuals,  it  is  exceedingly  difficult  to  differentiate  be- 
tween neurogenic  and  diarrhea  induced  by  simple  or  specific  lesions. 

Some  authorities,  with  reason,  attach  considerable  importance  to 
the  absence  of  mucus  from  the  stools,  attributable  to  the  transudation 
of  fluid  into  the  bowel  in  contradistinction  to  mucus,  pus,  and  blood 
which  appear  in  the  feces  where  organic  changes  are  present  in  the 
mucosa. 

Of  bowel  diseases,  membranous  colitis  is  most  often  confused 
with  neuropathic  diarrhea,  because  patients  thus  afiflicted  are  alwa>"s 
\"ery  nervous  once  the  ailment  has  fully  developed,  but  this  condition 
can  ordinarily  be  distinguished  from  it  by  the  frequent  attacks  of 
obstipation  incident  to  enterospasms,  and  the  presence  of  mucous 
casts  or  shreds  in  the  evacuations. 

With  the  exception  of  myxorrhea  membranacea,  practically  all 
forms  of  colitis,  because  of  their  exhausting  discharges,  loss  of  blood, 
and  accompanying  toxemia,  cause  rapid  emaciation  and  loss  of  weight, 
sallow  complexion,  anemia,  anorexia,  furred  tongue,  weakened  and 
rapid  pulse,  marked  gastro-intestinal  disturbances,  and  other  signs 
of  greatly  impaired  health,  all  of  which  manifestations  may  be  absent 
or  minimized  in  nervous  diarrhea,  which  usually  occurs  in  compara- 
tively healthy  individuals,  owing  to  the  fact  that  nutrition  is  dis- 
turbed to  a  less  degree. 

In  diagnosing  neurogenic  diarrhea  the  author  relies  chiefly  upon 
the  sudden  onset  and  periodicity  of  the  attacks,  marked  fluidity  of  the 
stools,  rapid  succession  in  which  the  evacuations  follow  each  other 
in  the  early  morning,  the  manifestation  or  presence  of  organic  or 
functional  ner\-e  disease  (hysteria,  tabes,  exophthalmic  goiter,  etc.), 
or  the  evidence  of  profound  psychic  emotion,  together  with  a  thorough 
investigation  of  the  abdominal  viscera,  an  analysis  of  the  feces,  and  a 
careful  digital  proctoscopic  and  sigmoidoscopic  examination  of  the 
rectum  and  sigmoid  flexure. 

Fecal  analysis  will  show  the  e\acuations  to  be  composed  largely 
of  a  serous  fluid  in  nervous  diarrhea,  and  soft  fecal  matter  contain- 
ing an  abundance  of  mucus  and  some  pus  and  blood  in  the  more 
common  types  of  diarrhea  (catarrhal  and  infective  enterocolitis). 

Instrumental  examination  of  the  bowel  materially  helps  to  clear 
up  the  diagnosis,  because  in  nervous  diarrhea  the  mucosa  shows  pale 


146  NEUROGENIC    DIARRHEA 

and  unchanged,  while  in  the  simple  and  infectious  types  of  entero- 
colitis it  appears  red,  swollen,  or  edematous,  and  there  are  erosions 
or  ulcers  variable  in  size  and  extent,  and  the  lesions  and  intervening 
mucosa  are  smeared  with  an  admixture  of  mucus,  pus,  and  blood. 
Medication  is  helpful  in  the  difTercntial  diagnosis  for  antidiarrheal 
remedies  which  are  known  to  control  the  usual  forms  of  loose  move- 
ments, but  do  little  if  any  good  when  diarrhea  is  caused  by  psychic 
impulses,  functional  or  organic  nervous  diseases.  Pariser  regards  ten- 
derness on  pressure  of  the  abdominal  ganglia  as  the  characteristic 
stigma  of  nervous  diarrhea,  but  this  diagnostic  sign  has  not  proved 
reliable  in  the  author's  hands.  A  differentiation  is  difficult  in  cases 
where  persons  previously  aflflicted  with  nervous  diarrhea  contract  en- 
teritis. 

Diarrhea  should  not  be  considered  as  neurogenic  and  attributed 
to  tabes  dorsalis,  exophthalmic  goiter,  neurasthenia,  hysteria,  migraine, 
or  other  organic  or  functional  nervous  ailments  except  when  there  are 
confirmative  evidences  of  their  existence  and  the  bowel  is  found  to  be 
intact. 

Treatment. — Before  outlining  the  treatment  it  is  necessary  to 
determine  whether  the  diarrhea  is  truly  neurotic  or  is  due  to  lesions 
of  the  intestine,  or  both,  because  the  therapeutic  measures  indicated 
in  the  two  conditions  vary  greatly.  Again,  when  hysteria,  neuras- 
thenia, or  other  nervous  disorder  are  directly  or  indirectly  responsible 
for  the  frequent  movements,  these  must  be  corrected,  otherwise  a  cure 
cannot  be  accomplished. 

Psychic  emotions  are  the  sole  cause  of  neurogenic  diarrhea  in  some 
instances  and  aggravate  it  in  others,  and  because  of  this  it  is  of  the 
utmost  importance  that  the  patient's  mentality  should  receive  due 
consideration  when  planning  the  treatment. 

In  the  handling  of  this  class  of  cases  much  more  can  be  accom- 
plished with  psychotherapy  and  physical  therapeutic  measures  for 
building  up  the  general  health  than  by  the  administration  of  drugs, 
which  temporarily  quiet  the  nervous  mechanism  and  leave  it  irritable 
when  their  effects  have  worn  off".  Neurotic  subjects  who  suffer  from 
diarrhea  consider  their  condition  serious,  and  should  not  be  told  that 
it  amounts  to  nothing,  otherwise  they  will  lose  confidence  and  dis- 
continue the  treatment;  nor  should  their  trouble  be  magnified,  which 
would  cause  them  to  worry,  and  lead  to  an  increased  number  of  evacu- 
ations. It  is  of  the  utmost  importance  for  the  physician  to  maintain 
a  cheerful  disposition  while  with  these  patients,  to  tell  them  that  they 
have  a  slight  ailment,  but  one  which  can  be  easily  corrected,  and 
encourage  them  daily  by  remarking  that  both  their  general  and  local 
conditions  ha\e  improved.  The  author  makes  it  a  rule  in  these  cases 
to  treat  the  bowel  with  soothing  oils,  sprays,  and  innocent  topical 
applications,  both  to  diminish  local  irritation  and  relieve  the  patient's 
mind.  This  is  the  sine  qua  non  of  the  treatment,  for  the  reason  that 
it  eases  the  patient's  mind,  owing  to  the  fact  that  it  convinces  him 
that  something  definite  is  being  done  to  effect  a  permanent  cure. 


TRKATMi:XT  1 47 

Soothing  electric  currents  and  light  friction  massage,  when  well 
borne,  are  helpful,  because  they  are  impressive,  soothe  the  nerves, 
encourage  sleep,  and  strengthen  the  muscles,  and  the  same  can  be 
said  of  h\drotherapy  judiciously  employed,  but  vibratory  treatments 
and  heavy  massage  are  contra-indicated  because  they  tend  to  irritate 
the  sensitive  nerves,  induce  insomnia,  and  increase  the  number  of 
movements. 

Some  indi\"iduals  can  remain  at  home,  come  to  the  of^ce,  and  be 
successfully  treated,  but  others  cannot,  because  improvement  is 
prevented  by  their  uncongenial  and  depressing  surroundings,  family 
wrangles,  business  worries,  or  other  factors  which  aggravate  their 
ner\ous  state.  Such  persons  should  be  sent  either  to  a  sanitarium, 
to  take  the  rest  cure  amid  quiet  surroundings  and  where  a  suit- 
able diet  can  be  prescribed  along  with  other  therapeutic  measures,  or 
to  the  country,  away  from  their  old  surroundings,  business  associates, 
friends,  and  relatives,  where  they  can  take  sufficient  exercise,  have 
congenial  companions,  spend  their  time  in  the  open  air,  and  overcome 
the  subo.xidation  and  insomnia  from  which  they  suffer.  At  the 
same  time  they  should  be  compelled  to  lead  a  regular  life  as  regards 
the  time  for  eating,  sleeping,  and  attending  to  the  calls  of  nature. 

The  diet  should  be  non-irritating,  bountiful,  and  nutritious,  and 
the  patient  should  be  advised  against  the  eating  of  foods  difficult  to 
digest  or  which  irritate  the  stomach  and  intestine,  and  the  drinking 
of  alcoholic,  iced,  or  carbonated  beverages,  which  tend  to  increase  the 
frequency  and  fluidity  of  the  movements. 

In  some  instances  a  cold  girdle,  applied  to  the  abdomen  in  the 
intervals  between  attacks,  makes  the  patient  feel  better  and  strength- 
ens the  abdominal  and  intestinal  musculature,  but  during  the  crises, 
when  there  is  griping  and  soreness  of  the  intestine,  cold  should  be  dis- 
placed by  hot  applications,  which  diminish  pain  and  irritability. 

When  heat  does  not  prove  effective,  and  the  evacuations  are  rapidly 
exhausting,  the  patient's  relief  is  obtained  by  a  hypodermic  injec- 
tion containing  morphin,  gr.  \  (0.015),  and  atropin,  gr.  y^o  (0.0006), 
which  may  be  repeated  in  one  hour  if  necessary,  or  these  remedies 
may  be  employed  in  suppositories  when  rectal  tenesmus  and  pain  are 
annoying. 

Astringent  remedies  are  contra-indicated  because  the\'  do  little  or 
no  good,  and  frequently  aggravate  the  condition  b\'  interfering  with 
the  digestive  secretions. 

Except  in  the  most  distressing  cases,  patients  afflicted  with  neuro- 
genic diarrhea  feel  perfectly  well  in  the  intervals  between  the  attacks, 
and  this  respite  should  be  taken  advantage  of  to  better  the  condition 
of  their  nervous  system  by  prescribing  tonics  to  improve  the  circu- 
lation, strengthen  the  nerves,  and  tone  up  the  digestive  apparatus, 
but  in  doing  this  drugs  should  not  be  prescribed  which  would  tend 
to  upset  the  stomach  or  disturb  digestion. 

Of  the  various  remedies  employed  for  the  purpose,  arsenic,  iron 
preparations,  and  nutrient  tonic  emulsions,  such  as  Russell's,  have 


148  NEUROGENIC    DIARRHEA 

proved  most  useful.     Charcot  has  obtained  good  results  with  arsenic 
and  bromid  used  as  follows: 

R.     Sol.  arsenic.  Fowleri  )  .-    ,^.  ,      ^      -.t 

Aq.  amygdal.  amar.     ) ^^  ^J  (4.0).-^. 

Det.  ad  vitripat. 
Sig. — Beginning  with  4  drops  daily  after  meals,  increase  the  dose  i  drop  every  second 
day  until  20  drops  are  taken,  then  drop  back  to  4,  and  repeat  the  process.    Give  at  night 
the  effervescent  salt  of  Sandow  in  milk  or  water. 

The  following  combination  is  to  be  relied  upon,  both  to  quiet  the 
mental  state,  encourage  sleep,  and  to  diminish  the  number  of  evacua- 
tions when  the  patient  is  extremely  nervous: 

R.     Tinct.  belladonnae )  --  /      s 

'      T'  I-  u  ,.•  ,- aa  gr.  x.xx  (2.0); 

Kaui  bromati         j  &  v      /  > 

Xatrii  bromati gr.  xlv  (3.0) ; 

Aq.  font q.  s.  ad   5ivss  (150.0). — M. 

Sig.— A  tablespoonful  three  or  four  times  daily. 

In  some  instances  it  has  been  found  necessary  to  prescribe  veronal, 
trional,  or  sulphonal,  gr.  xv  (0.97),  bromid  of  soda,  gr.  xxx  (1.95),  or, 
in  extreme  cases,  the  latter  in  combination  with  chloral,  gr.  x  (0.60), 
to  quiet  the  nerves  and  secure  much-needed  sleep. 

In  the  handling  of  this  type  of  diarrhea  it  is  well  to  bear  in  mind 
that  there  are  frequent  intervals  when  the  regularity  of  the  evacua- 
tions is  not  disturbed.  During  such  periods,  hygienic,  dietetic,  and 
tonic  therapeutic  measures  should  be  continued  and  antidiarrheal 
agents  stopped,  but  during  crises  tonics  should  be  side-tracked  for 
remedies  which  can  be  depended  upon  to  minimize  or  control  the 
pain  and  exhausting  diarrhea.  For  this  purpose  hypodermics  of 
morphin,  gr.  I  to  j  (0.008-0.015).  the  tincture  of  opium,  nj  x  (0.60), 
or  powdered  opium,  gr.  j  to  iss  (0.06-0.09),  administered  two  or  three 
times  daily  until  pain  is  arrested  and  the  movements  are  diminished, 
are  the  most  reliable  remedies,  but  when  there  is  considerable  intes- 
tinal uneasiness,  cramps,  or  enterospasm,  the  extract  of  belladonna, 
gr.  I  (0.008),  should  be  combined  with  an  opiate. 

Little  or  nothing  is  to  be  expected  from  antiseptics  or  the  ordinary 
remedies  which  are  serviceable  in  other  types  of  diarrhea. 

Frequently  there  coexists  with  neurogenic  a  diarrhea  incident  to 
gastritis,  enteritis,  or  enterocolitis,  and  under  such  circumstances  it 
is  advisable  to  treat  both  conditions.  In  addition  to  the  above,  it  is 
necessary  to  institute  moderate  or  strict  dietetic  measures.  Spices, 
greasy,  sour,  and  foods  which  contain  considerable  cellulose  and  leave 
a  large  irritating  residue  should  be  prohibited,  and  those  that  are 
bland,  fluid,  or  semisolid  and  digestible  substituted  (milk  and  lime- 
water,  buttermilk,  broth,  gruels,  etc.).  Ice-cream,  cold  carbonated 
drinks,  and  alcohol  should  be  limited  or  discarded  altogether,  because 
they  usually  increase  the  evacuations. 

When  there  is  excessive  putrefaction  and  enteritis,  as  is  evidenced 
by  regular  frequent  daily  evacuations  containing  mucus,  blood,  and 


TREATMENT  I 49 

pus,  antiseptic  agents,  such  as  bismuth  suhnitrate  or  salol,  gr.  x 
(0.60);  beta-naphthol.  gr.  ij  to  v  (0.12-0.30),  and  astringent  reme- 
dies, such  as  tannalbin,  ichthalbin,  ichthoform,  gr.  x  (0.60),  adminis- 
tered three  times  daily,  add  very  mucii  to  the  patient's  comfort  and 
frequently  arrest  or  limit  the  number  of  movements. 

A  great  deal  can  l)e  done  to  alleviate  the  patient's  condition  when 
there  is  catarrh  or  enterocolitis  by  daily  irrigating  the  l)o\vel  from  be- 
low by  way  of  the  anus,  or  from  above  through  an  artificial  appendi- 
ceal or  cecal  opening. 

In  the  presence  of  simple  catarrh  much  benefit  is  to  be  derived  fr(jm 
a  normal  saline,  Carlsbad  salt,  or  sulphate  of  magnesia  solution. 
5ss  to  j  (15-30)  to  water  Oij  (1000),  but  when  there  are  erosions  or 
ulcers,  warm  mild  antiseptics  or  astringent  solutions,  such  as  boric 
acid,  permanganate  of  potassium,  ichthyol,  and  salicylate  of  soda, 
I  to  2  per  cent.,  etc.,  should  be  employed  to  flush  the  bowel  daily  or 
three  times  weekly,  according  to  the  severity  of  the  diarrhea.  When 
the  e\'acuations  are  very  frequent,  and  contain  an  abundance  of  pus 
and  blood,  a  silver  nitrate  solution,  gr.  x  to  Oj  (0.60-500),  should  be 
substituted  for  the  above  remedies;  but  when  enterospasm  is  trouble- 
some the  latter  should  be  alternated  every  other  day  with  warm  min- 
eral, olive,  cotton-seed,  or  crude  oil,  poured  directly  into  the  colon 
through  a  sigmoidoscope,  with  the  patient  in  the  inverted  posture; 
this  soothes  the  infiamed  mucosa  and  muscular  irritability  of  the 
bowel. 


CHAPTER  XIII 
TOXIC  DIARRHEA 

FOOD,   CANNED  GOODS,   BACTERIAL   (PTOMAIN)    POISONING 

Acute  and  chronic  diarrheas,  mild,  severe,  and  fatal,  are  conse- 
quent upon  bacteria,  ptomains,  contamination  through  metal  con- 
tainers, and  other  poisons  accidentally  eaten  very  much  more  fre- 
quently than  is  generally  believed,  irrespective  of  the  fact  that 
gastro-intestinal  and  nerve  irritation  from  these  sources  are  being 
detected  more  often  than  formerly,  and  physicians  and  the  laity 
have  been  educated  to  the  importance  of  properly  selecting  and  pro- 
tecting food. 

Formerly  it  was  customary  to  consider  all  toxemias  induced  by 
food  products  as  resulting  from  ptomains,  but  more  recent  investi- 
gations have  demonstrated  beyond  question  that  the  poisoning  is 
more  frequently  due  to  infection  from  ingested  bacteria  than  to  the 
toxins  generated  by  them.  In  some  quarters  the  chief  source  of  poison- 
ing was  thought  to  be  due  to  contamination  of  the  food  by  metal 
when  canned,  or  cooked  in  a  brass  vessel,  but,  while  this  is  possible 
and  occasionally  occurs,  we  now  know  that  the  disturbance  in  the 
vast  majority  of  instances  is  caused  by  bacteria  or  their  toxins. 

The  unhealthy  article  of  diet  causing  the  trouble  may  have  become 
contaminated  by  pathogenic  germs  through  an  animal  having  been 
diseased,  putrefying  before  being  eaten,  or,  when  healthy,  being 
left  exposed  to  the  myriads  of  micro-organisms  in  the  air.  Naturally, 
when  food  is  consumed  raw,  poisoning  is  more  apt  to  follow  than  when 
the  meat  is  boiled  or  roasted,  because  nothing  is  done  to  kill  the 
bacteria,  but,  while  this  is  true,  it  is  well  to  bear  in  mind  that  their 
products,  the  ptomains,  are  frequently  not  destroyed  in  this  way,  and 
may  remain  to  cause  profound  toxic  manifestations  after  thorough 
cooking. 

Poisoning  has  followed  the  eating  of  a  large  variety  of  foods,  and 
of  these,  veal,  beef,  pork,  sausage,  chicken  salad,  potted  tongue,  lob- 
sters, oysters,  crabs,  clams,  fish,  canned  goods  (all  sorts),  ice-cream, 
custard,  puddings,  potatoes,  beans,  and  mushrooms  have  been  most 
frequently  associated  with  and  contained  tiie  toxin  responsible  for 
diarrhea  from  food-poisoning. 

Meat-poisoning,  Diarrhea  from. — A  perusal  of  the  literature  indi- 
cates that  diarrhea  from  food-poisoning  is  induced  more  frequently 
by  meat  than  other  articles  of  diet  known  to  have  caused  toxemia. 
The  disturbance  does  not  always  result  from  a  particular  kind  of  meat, 
cases  having  been  observed  where  it  followed  the  eating  of  beef,  mut- 
150 


TOXEMIA    FROM    THE    MEAT    OF    DISEASED    ANIMALS  I5I 

ton,  pork,  veal,  mince-meat,  chicken  sakul,  sausages,  and  various 
canned  meats,  often  raw  and  less  frequently  when  cooked. 

Bollinger,  who  has  made  an  elaborate  study  of  meat-poisoning, 
believes  that  in  four-fifths  of  the  cases  it  results  from  eating  the 
meat  of  animals  already  diseased  when  killed.  Bacteria  may  flourish 
in  raw  or  slightly  cooked  meat,  and  are  destroyed  by  thorough  boil- 
ing or  roasting,  but  their  ptomains  may  be  rendered  inert  or  modified 
by  cooking  or  retain  their  toxic  qualities  thereafter.  Most  persons 
believe  that  smoking  meat  destroys  bacteria,  counteracts  and  renders 
the  toxins  inert,  and  prevents  its  future  infection,  but  epidemics  have 
often  followed  the  eating  of  smoked  meat  and  herring,  and  investiga- 
tion of  these  cases  has  shown  that  this  smoking  does  not  always  render 
meat  proof  against  bacteria  or  their  toxins. 

Badly  putrefied  meat  is  readily  detectable  from  its  odor,  but  when 
it  is  but  slightly  tainted  it  is  likely  to  be  eaten,  since  it  looks,  smells, 
and  tastes  normal.  Chicken  and  game  have  been  known  to  undergo 
bacterial  changes  while  in  cold  storage,  and  they  readily  decay  when 
removed  from  the  cold.  That  the  consumption  of  putrefying  food 
does  not  always  make  one  ill  is  evidenced  by  the  fact  that  ducks  and 
partridges  are  often  eaten  when  very  "high"  without  causing  any 
disturbance.  Meat-poisoned  stools  are  but  slightly  infectious,  the 
writer  having  been  able  to  find  but  a  single  case,  that  of  a  woman, 
who  became  infected  from  the  discharges  of  her  boy  while  nursing 
him  for  ptomain-poisoning. 

A  description  of  the  patlioloiiic  findings  in  meat  infection  and  pto- 
main-poisoning requires  but  l)rief  consideration,  because  they  are 
unimportant  in  comparison  with  the  serious  manifestations  to  be 
relieved. 

In  all  types  of  meat-poisoning  except  botulism  (sausage-poisoning) 
organic  changes  are  confined  chiefly  to  the  digestive  tract,  as  is  shown 
by  the  gastro-enteritis  which  obtains,  and  results  from  congestion, 
slight  edema,  and  sometimes  hemorrhagic  spots  in  the  mucosa.  Hem- 
orrhagic areas  may  also  appear  in  the  serosa  of  the  pleura,  pericardium, 
and  skin.  In  particularly  virulent  cases  the  follicles  are  swollen, 
undergo  necrosis,  ulcers  are  formed  and  bleeding  ensues,  and  some- 
times enlargement  of  the  mesenteric  glands  and  spleen  are  manifest. 

In  sausage-poisoning  the  central  nervous  system  is  profoundly 
affected,  leading  to  secretory  disturbances  and  muscular  paralysis. 

Meat  toxemias  may  be  grouped  into  those  induced  by  (a)  con- 
suming meat  of  diseased  animals,  (/;)  eating  that  which  is  putrefied, 
and  (c)  partaking  of  unhealthy  sausages. 

Toxemia  from  the  Meat  of  Diseased  Animals. — Numerous  epi- 
demics ha\e  occurred  where  soldiers  in  large  numbers  or  other  per- 
sons congregated  together  (family  parties,  etc.)  have  suffered  mildly, 
severely,  or  fatally  from  diarrhea  and  other  distressing  manifesta- 
tions which  followed  the  eating  of  meat  derived  from  animals  diseased 
when  slaughtered. 

Food  toxemias  have  not  only  been  traced  to  the  eating  of  dis- 


152  TOXIC    DIARRHEA 

eased  veal.  beef,  etc.,  which  was  eaten,  but  also  to  the  flesh  of  healthy 
animals  which  had  become  contaminated  through  contact  with  dis- 
eased meat.  This  form  of  poisoning  has  usually  followed  consumption 
of  the  meat  of  calves  that  had  infected  navels  or  other  disease,  cows 
having  gastro-enteritis  or  unhealthy  udders,  and  it  has  resulted  from 
the  eating  of  meat  from  diseased  steers,  hogs,  horses  (with  abscesses), 
and  sheep.  The  author  formerly  lived  in  Kansas  City,  where  there 
are  numerous  slaughter-houses,  and  of  his  personal  knowledge  knows 
that  it  was  often  the  practice  of  farmers  and  cattlemen  in  the  West 
to  rush  diseased  stock  to  market  along  with  healthy,  that  they  might 
avoid  the  loss  which  would  otherwise  follow  from  animal  epidemics 
then  killing  their  stock.  This  practice  still  obtains,  but  to  a  less 
degree,  owing  to  the  fact  that  animals  to  be  slaughtered  must  first 
undergo  government  inspection. 

The  bacteriology  of  food-poisoning  due  to  eating  the  meat  of 
diseased  animals  is  not  well  understood,  but  the  paratyphoid  and 
Bacillus  enteritidis  are  considered  to  be  the  chief  etiologic  factors 
because  of  the  frequency  with  which  they  ha\'e  been  associated  with 
this  type  of  infection.  The  trouble,  however,  may  be  due  to  either  of 
these  germs  or  to  their  products  (ptomains)  which  have  formed  in  the 
meat  before  or  after  it  was  ingested. 

Toxemia  from  Decayed  or  Putrefied  Meat. — Diarrhea  from  this 
source  is  encountered  very  much  more  frequently  in  the  summer 
than  in  winter  months,  because  heat  favors  the  multiplication  and 
activity  of  putrefactive  bacteria  (proteus  group).  This  form  of 
meat-poisoning  may  follow  the  ingestion  of  the  flesh  of  both  healthy 
and  diseased  animals,  particularly  when  chopped  up  and  exposed 
to  the  air  for  a  considerable  time  in  a  warm  place,  and  preservative 
measures  have  not  been  taken  to  protect  it. 

While  numerous  kinds  of  putrefactive  bacteria  may  be  present, 
the  poisoning  from  decayed  meat  is  usually  traceable  to  the  proteus 
group  alone,  or  associated  with  colon  bacilli,  although  in  one  recorded 
instance  the  toxemia  was  due  to  the  Bacillus  subtilis. 

Toxemia  from  Sausage-poisoning  (Botulism). — Food-poisoning 
from  this  source  has  been  obserxed  more  frequently  in  German-speak- 
ing countries  than  elsewhere,  because  Germans  are  large  consumers 
of  sausage,  and  frequently  eat  it  raw  or  cold,  which  offers  a  greater 
chance  for  infection,  since  nothing  is  done  to  destroy  the  con- 
tained bacteria  or  neutralize  their  toxins.  Toxemia  from  this  source 
has  been  traced  to  diseased  animals,  those  in  poor  condition,  careless 
handling  of  the  meat,  its  insufficient  smoking,  and  to  the  time  elapsed 
between  slaughtering  of  the  animal  and  manufacture  of  the  sausage. 
The  pathogenicity  in  sausage-poisoning  has  been  attributed  to  the 
Bacillus  botulinis,  an  anaerobic  germ,  which  has  also  been  associated 
with  poisoning  from  the  eating  of  beans  and  ham. 

Poisoning  from  Milk  and  Its  Products,  Diarrhea  in. — Infected  milk 
is  occasionally  responsible  for  loose  movements  in  adults,  and  is  con- 
ceded to  be  the  most  frecjuent  etiologic  factor  in  the  diarrhea  of  in- 


POISONING    FROM    MILK    AND    ITS    PRODUCTS,    DIARRHHA    IN        1 53 

fants,  in  whom  ilu-  iiiortalitN-  is  very  great,  particularly  among  artifi- 
cialK'  (bottle)  fed  children  during  the  heated  summer  months. 

Milk,  ice-cream,  custards,  crcar}i-piiffs,  sauces,  puddings,  and  cheese 
have  all  caused  poisoning  which  induced  gastro-enteritis  and  diar- 
rhea. In  some  instances  their  toxic  effect  produced  nothing  more 
than  slight  temporary  annoyance,  while  in  others  distressing  mani- 
festations or  death  ensued.  In  some  instances  poisoning  was  confined 
to  an  individual  or  famiK'  part\',  while  in  others  a  large  number  of 
persons  (soldiers,  etc.)  were  affected  by  the  contaminated  milk  or  its 
products. 

Bacilli  may  contaminate  the  milk  oi  diseased  animals  affected  with 
tuberculosis,  but  most  often  it  becomes  infected  through  dust  on  the 
animal,  filthy  hands  of  the  milker,  unclean  receptacles,  or  from  ex- 
posure when  left  uncovered  for  a  considerable  pericxl.  Milk  contains 
myriads  of  man\-  different  types  of  bacteria,  but  the  colon  and  the 
Bacillus  enteritidis  of  Gartner  are  thought  to  be  the  most  frequent 
disturbing  factors,  while  the  Bacillus  enteritidis  sporogenes,  staphylo- 
cocci, streptococci,  paratyphoid,  and  possibly  typhoid  bacillus  have  been 
frequently  found. 

In  addition,  Vaughan  has  pointed  out  that  the  non-pathogenic 
or  saprophytic  germs  frequently  contaminate  milk  and  its  by-products 
and  form  ptomains,  particularly  tyrotoxicon,  which  is  capable  of  incit- 
ing a  choleriform  diarrhea. 

Ice-cream  has  \"ery  frequently  been  responsible  f(^r  diarrhea.  \mt 
not  so  often  because  of  its  low  temperature  as  it  is  to  the  fact  that  it 
has  become  poisonous  through  flavoring  extract  or  the  container. 
Usually  poisoning  from  this  source  has  followed  the  eating  of  vanilla 
ice-cream,  and  the  toxemia  has  been  attributed  to  the  flavoring  ex- 
tract, but  more  recent  investigations,  particularly  those  of  Wassermann 
and  Vaughan,  have  demonstrated  the  bacterial  origin  of  the  poison. 

The  symptoms  of  poisoning  induced  by  milk,  ice-cream,  custards, 
pudding,  cheese,  or  other  food  having  a  milk  basis  may  be  slight  or 
very  grave,  and  are  always  more  dangerous  to  infants  and  children 
than  adults.  Sometimes  poisoning  does  nothing  more  than  upset  the 
stomach  and  slightly  increase  evacuations,  but  at  others  toxemia  is 
marked  and  the  patient  suffers  from  chilly  sensations,  headache, 
dizziness,  disturbed  vision,  subnormal  temperature,  abdominal 
tenderness  and  pain,  cramps,  diarrhea,  bloody  stools,  persistent  rectal 
tenesmus,  exhaustion,  and,  in  \ery  aggravated  cases,  unconscious- 
ness and  collapse.  Poisoning  from  cheese  frequently  does  not  manifest 
itself  until  from  six  to  fifteen  hours  after  it  has  been  eaten,  but  the 
symptoms  from  ice-cream,  custard,  and  milk  poisoning  are  frequently 
noticeable  immediately,  or,  at  the  latest,  in  from  one  to  two  hours. 

The  diagnosis  is  determined  by  ascertaining  if  the  milk  came  from 
a  healthy  cow,  if  it  has  been  contaminated  by  dirt  in  the  handling  or 
through  exposure,  and  by  examining  the  milk,  cheese,  custard,  or 
pudding  for  bacteria  and  toxins  which  cause  these  forms  of  toxemia. 

Diarrhea  from  cheese-poisoning  is  fairly  common,  and  the  author 


154  TOXIC    DIARRHEA 

recently  treated  a  patient  who  almost  died  from  this  type  of  loose 
movements  and  the  violent  vomiting  which  accompanied  them. 
In  this  and  other  instances  there  was  nothing  about  the  color,  odor, 
or  taste  of  the  cheese  which  would  lead  one  to  suspect  that  it  was 
poisonous.  Vaughan  attributes  the  toxic  action  of  the  cheese  to  the 
alkaloidal  tyrotoxicon,  but  more  recent  investigators  indicate  that  the 
disturbance  is  bacterial,  and  it  is  not  unreasonable  to  suppose  that  the 
toxemia  may  be  due  to  either  or  both. 

At  different  times  cheese-poisoning  has  been  attributed  to  a 
bacillus  of  the  colon  type  (Hoist),  anaerobic  (Pfliiger),  similar  to 
Bacillus  bottdimis,  typhoid  and  paratyphoid  bacillus,  and  to  the 
proteus  bacillus. 

Fish  and  Shell-fish  Poisoning,  Diarrhea  from. — Toxemia  from  the 
eating  of  fish  or  their  roe  is  met  with  now  and  then,  but  does  not 
occur  as  frequently  as  poisoning  from  oysters,  crabs,  clams,  mussels, 
snails,  and  other  shell-fish. 

Fish  toxemia  may  ensue  from  the  eating  of  fish  (sturgeon)  which 
are  naturally  poisonous  at  all  times,  and  others  which  are  toxic  only 
during  the  spawning  season.  One  is  more  apt,  however,  to  become 
poisoned  from  the  eating  of  the  roe  of  pike,  German  carp,  and  the 
Japanese  fugu  than  from  meat,  and  it  is  claimed  that  the  liver  and  bile 
of  certain  fish  have  been  known  to  produce  ill  efi"ects. 

In  this  country  ptomain-poisoning  has  frequently  occurred  from 
eating  oysters,  lobsters,  crabs,  clams,  mussels,  and,  rarely,  snails. 
In  some  instances  they  were  contaminated  while  in  their  beds 
through  sewage,  and  became  carriers  of  typhoid,  dysenteric,  and 
other  types  of  infecting  agents.  Fish  and  shell-fish  toxemias  may  be 
induced  by  the  eating  of  them  when  already  diseased  before  being 
caught,  or  where  they  were  healthy  in  the  beginning,  but  became 
infected  through  uncleanliness  or  carelessness,  and  were  permitted 
to  become  infected  before  being  cooked  or  served  raw.  Poisoning 
may  ensue  as  a  result  of  bacterial  infection  or  their  toxins,  or  both, 
but  the  former  can  be  destroyed  by  boiling,  while  the  latter  cannot 
in  every  instance,  and  it  is  well  to  bear  in  mind  that  unconsumed 
cooked  meat  may  easily  become  infected  when  left  exposed,  particu- 
larly in  warm  weather. 

The  manifestations  are  mild  when  putrefaction  is  just  beginning, 
but  the  symptoms  produced  by  eating  fish  and  shell-fish  which  have 
undergone  marked  putrefaction  (noticeable  by  its  odor)  are  very 
much  more  pronounced,  owing  to  the  increased  number  and  activity 
of  contained  bacilli  and  their  toxic  products. 

To  obviate  danger  from  this  source  fish  more  than  twenty-four 
hours  old  should  not  be  eaten  unless  they  have  been  properly  iced, 
and  the  same  applies  to  cooked  fish  and  shell-fish;  nor  should  fresh 
fish,  oysters,  lobsters,  etc.,  be  permitted  to  come  in  contact  with  those 
caught  or  cooked  earlier  or  placed  in  a  refrigerator  before  cleansing, 
otherwise  they  are  likely  to  become  infected;  for  the  same  reason, 
the  eating  of  canned  oysters,  lobsters,  or  fish,  which  have  been  opened 


POISONING    FROM    CANNED    GOODS,    DIARRHEA    IN  1 55 

and  allowed  to  stand  is  dangerous,  and  it  is  well  to  use  only  fresh 
dressings  with  them,  because  poisoning  has  resulted  from  this  source. 

Infection  in  this  class  of  cases  has  been  attributed  to  the  proteus, 
colon,  and  paratyphoid  bacillus,  alone  or  collectively,  in  different  cases, 
and  other  organisms  are  supposed  to  participate,  but  their  identity 
thus  far  has  not  been  established. 

Poisoning  from  Canned  Goods,  Diarrhea  in. — During  the  past 
decade  tlie  amount  of  canned  goods  consumed  has  increased  at  an 
enormous  rate,  owing  to  their  cheapness,  greater  assortment,  being 
readily  and  easily  prepared  for  the  table,  because  many  thousands  of 
persons  of  limited  means  are  compelled  to  live  in  diminutive  apart- 
ments having  small  kitchens  or  kitchenettes  which  are  not  suited  for 
the  preparation  of  more  elaborate  dishes;  the  limited  time  left  for 
cooking  by  individuals  who  must  work  for  a  living;  and,  finally,  they 
are  used  extensively  because  they  can  be  easily  carried  and  indefinitely 
kept  by  fishermen,  hunters,  explorers,  soldiers,  and  others  who  are  on 
the  move  or  go  to  out-of-the-way  places.  In  fact,  with  their  aid  one 
can  within  a  few  moments  prepare  a  nice  hot  course  dinner,  including 
everything  from  soup  to  dessert. 

A  few  years  ago,  when  canned  goods  first  became  popular,  many 
cases  of  poisoning  were  reported  from  this  source;  and  this  led  to  an 
investigation  by  the  authorities,  who  discovered  that  the  trouble  was 
due  largely  to  the  selection  of  imperfect  or  spoiled  foods,  uncleanli- 
ness,  their  careless  canning,  insufficient  sterilization  or  undue  exposure 
to  pathogenic  bacteria,  which  later  results  in  their  decomposition  and 
the  formation  of  poisonous  toxins.  Recently,  however,  poisoning 
from  this  source  has  not  been  frequent,  because  the  authorities  now 
maintain  a  supervision  over  the  canning  of  food. 

When  toxemia  results  from  bacterial  poisoning  it  may  be  from 
the  canning  of  decomposed  products,  sound  food  stuffs  which  contain 
germs  not  destroyed  in  the  preserving  process,  or  by  virulent  toxins 
in  the  food  formed  by  bacteria  and  not  always  destroyed  by  heat. 
While  meat-  and  fish-poisoning  are  very  much  more  common,  toxemia 
has  been  observed  on  a  number  of  occasions  to  follow  the  eating  of 
canned  vegetables,  particularly  string-beans,  and,  strange  as  it  may 
seem,  in  the  two  most  celebrated  outbreaks  from  this  source,  those  of 
Darmstadt,  1904,  and  Leipzig,  1906,  the  trouble  was  attributed  in  the 
former  to  a  germ  identical  with  the  Bacillus  butyriciis,  and  in  the  latter 
to  colon  and  paratyphoid  bacilli — bacteria  responsible  for  most  meat 
toxemias. 

As  a  rule,  when  marked  bacterial  decomposition  has  taken  place 
it  causes  what  is  known  as  a  "blown  can,"  or  one  wherein  the  ends  of 
the  tin  are  rounded  and  bulging,  which  in  itself  evidences  the  poison- 
ous nature  of  the  contents  and  should  warn  the  purchaser  not  to  buy 
the  goods.  The  laity,  even  at  the  present  time,  believe  that  the 
poisonings  that  follow  the  eating  of  canned  food  are  practically  always 
due  to  the  metal  in  the  can  which  contaminates  its  contents,  but  it  has 
been  demonstrated   by   numerous  investigators  that  to.xemia  rarely 


156  TOXIC    DIARRHEA 

results  from  this  source.  This  type  of  poisoning  may  be  caused  by 
either  tin  or  lead,  the  latter  being  by  far  the  most  frequent.  It  is  said 
that  in  Germany  toxemia  has  not  arisen  from  either  of  these  sources 
on  account  of  the  law  providing  that  the  tin  used  shall  not  contain 
more  than  i  per  cent.,  nor  the  solder  10  per  cent.,  of  lead. 

Lehmann  has  pointed  out  that  the  amount  of  contained  tin  in- 
creases the  longer  the  contents  remain  in  the  can;  is  greater  in  de- 
composed canned  foods  and  in  pickled  fish  or  herring,  where  the  acid 
favors  the  breaking  up  of  the  tin.  Consequently,  fruit  and  the  like 
containing  acid  is  less  apt  to  cause  trouble  when  preserved  in  glass  or 
crockery.  Poisoning  from  copper  has  been  known  to  follow  the 
boiling  of  vegetables  and  acid  substances  in  copper-lined  containers, 
but  this  must  be  extremely  rare,  since  much  of  the  cooking  in  the 
larger  hotels  is  done  in  copper  vessels  and  poisoning  does  not  result. 
In  these  supposed  cases  the  poisoning  was  probably  due  to  the  lead 
which  reached  the  food  where  the  copper  covering  had  become  defect- 
ive. Bolduan  says  that  the  presence  of  lead  can  be  determined  by 
boiling  a  4  per  cent,  solution  of  acetic  acid  in  the  vessel  for  one-half 
hour,  and  then  passing  sulphuretted  hydrogen  through  it,  when  a 
black  discoloration  or  precipitate  shows  the  presence  of  lead. 

The  symptoms  of  toxemia  consequent  upon  the  consumption  of 
contaminated  canned  goods  \aries  somewhat  according  to  the  char- 
acter of  the  food  and  contained  toxins.  In  the  cases  of  Fischer, 
where  21  persons  were  poisoned  by  beaji  salad  and  11  died,  the  mani- 
festations of  the  toxemia  were  very  severe,  appeared  one  or  two  da>"s 
later,  and  were  similar  to  those  described  under  sausage-poisoning. 
Autopsy  showed  congestion  of  the  intestine  with  hemorrhagic  spots 
beneath  the  mucosa.  While  in  the  Leipzig  outbreak,  due  to  string- 
beans,  all  of  the  250  persons  affected  recovered,  and  the  dizziness  and 
gastro-intestinal  manifestations,  including  diarrhea,  came  on  within 
a  few  hours,  and  lasted  but  two  or  three,  or  at  most  four  days,  leaving 
no  ill  effects,  while  the  recovered  Fischer  cases  had  a  very  prolonged 
convalescence.  Because  of  the  long  time  which  elapsed  in  Fischer's 
cases,  and  the  short  period  intervening  between  the  eating  of  the 
beans  and  onset  of  the  symptoms  in  the  Leipzig  cases,  it  would  seem 
that  poisoning  in  the  former  was  due  to  bacterial  action,  and  the  latter 
instances  to  their  toxins. 

The  diagnosis  depends  largely  upon  obtaining  a  history  as  to  the 
nature  of  food  which  has  been  eaten,  and  in  examining  the  container 
and  a  sample  of  the  food  to  determine  if  bacteria,  toxins,  or  chemicals 
are  present  which  might  cause  trouble. 

From  what  has  already  been  said,  it  can  be  inferred  that  the 
prognosis  may  be  serious  in  some  and  favorable  in  other  cases,  de- 
pending upon  the  virulency  of  the  poison  and  resistance  of  the  patient. 

Potato-poisoning,  Diarrhea  of. — A  few  cases  of  poisoning  from 
potato  salad  have  been  recorded,  but  in  the  vast  majority  of  in- 
stances where  the  toxic  element  of  potatoes  has  been  sufficiently 
virulent  to  cause  gastro-intestinal    and    other  severe  manifestations 


MUSHROOM    (mUSCARIN)    POISONING,    DIARRHEA    OF  1 57 

the  poisoninti;  has  occurred  amoii.u;  soldiers  or  other  assemblages  where 
large  amounts  of  food  ha\e  been  poorly  selected,  handled  by  unclean 
hands,  or  improperly  cooked.  This  disturbance  may  be  brought  on 
by  eating  green,  diseased,  shrunken-up,  discolored,  or  actively 
sprouting  potatoes,  and  is  in  most  instances  supposed  to  be  due  to  the 
contained  solanin  which  is  present  at  all  times,  but  in  increased 
amounts  under  the  abo\e  circumstances. 

Solanin  is  found  in  all  parts  of  the  potato,  but  is  most  abundant 
in  the  peel,  and  gradually  decreases  from  there  toward  the  center. 
Authorities  on  this  type  of  poisoning  are  inclined  to  the  belief  that 
toxemia  results  more  frequently  through  bacterial  action  than  through 
solanin,  which  must  be  consumed  in  large  amounts  to  produce  aggra- 
vating or  dangerous  symptoms.  One  is  led  to  this  conclusion  because 
in  later  years  individual  poisoning  and  outbreaks  among  soldiers 
have  followed  eating  potatoes,  or  the  salad  from  them,  which  were 
peeled  in  large  quantities  the  night  or  even  a  longer  time  before  their 
consumption.  Since  solanin  is  largely  contained  in  the  peel,  and  is 
not  materially  increased,  if  at  all,  by  previous  peeling  of  the  potato, 
it  would  seem  that  the  trouble  might  be  due  to  infection,  either  from 
their  handling  or  the  setting  in  of  bacterial  decomposition  upon  the 
uncovered  potatoes.  Dieudonne  has  pointed  out  that  proteus  bacilli 
are  the  inciting  micro-organisms  in  the  decomposition   process. 

In  the  Hammelburg  instance,  where  i8o  soldiers  were  poisoned 
by  potato  salad,  the  above  micro-organisms  were  found  in  abundance, 
and  mice  fed  upon  the  salad  died  within  a  day  of  severe  gastro-intes- 
tinal  symptoms,  and  it  was  found  that  the  poisoning  resulted  from  a 
toxin  formed  upon  the  potato  by  the  bacilli  during  warm  weather. 

Bolduan  has  suggested  that  other  bacteria  may  be  etiologic 
factors,  and  that  since  typhoid  and  paratyphoid  bacilli  grow  well 
upon  potatoes,  these  organisms  should  be  sought  for  in  the  micro- 
scopic examination. 

The  symptoms  vary  in  potato-poisoning,  but  in  typic  cases  they  are 
fairly  characteristic.  Usually  the  patient  first  complains  of  head- 
aches, which  are  quickly  followed  by  gastro-enterospasms  and  a 
severe  type  of  diarrhea  which  produces  marked  exhaustion.  In 
aggravated  cases  there  may  be  a  rise  in  the  temperature,  fast  pulse, 
dilated  pupils,  feeling  of  faintness,  and  occasionally  the  patient 
complains  of  chilling,  lassitude,  and  may  have  nausea  and  vomiting, 
but  rarely  if  ever  dies.  Usually  they  recover  in  from  two  or  three  days 
to  a  week,  but  when  the  poisoning  is  severe,  the  gastro-intestinal 
tract  may  remain  irritable  for  a  longer  time  to  continue  the  diarrhea. 

Mushroom  (Muscarin)  Poisoning,  Diarrhea  of. — There  are  several 
varieties  of  mushrooms  which  may  be  cultivated  or  found  growing 
wild,  some  of  which  are  harmless  edibles,  while  others  are  extremely 
toxic  because  of  the  alkaloid,  muscarin,  contained  in  them.  Mush- 
rooms should  never  be  eaten  until  after  they  ha\e  been  dried  and 
boiled,  because  in  this  way  only  can  the  muscarin  esca|)e  through 
evaporation. 


158  TOXIC    DIARRHEA 

Gastric  and  intestinal  manifestations  are  invariably  present  in 
mushroom-poisoning.  At  first  there  is  nausea,  vomiting,  and  pain 
in  the  stomach  and  cramps  in  the  lower  part  of  the  abdomen,  diar- 
rhea, jaundice,  and  hemoglobinuria,  but  later  the  pulse-beat  is  re- 
tarded, there  is  imperfect  vision,  and  in  severe  cases  coma  and  con- 
vulsions. 

Grain-  or  Seed-poisoning,  Diarrhea  of. — Gastro-intestinal  dis- 
turbances and  diarrhea  have  been  known  to  follow  the  eating  of 
spoiled  or  contaminated  grain  food  stufYs.  such  as  r\-e.  corn,  chicken- 
peas,  and  the  symptom-complex  arising  from  these  forms  of  toxemia 
have  been  designated  ergotismiis,  maidismus  {pellagra),  and  lathyris- 
mus.  In  all  the  trouble  has  ensued  from  the  eating  of  bread  or  other 
edibles  prepared  from  the  meal  of  the  above-mentioned  grains. 

Ergotismiis,  which  occurred  more  frequently  among  early  settlers, 
is  attributed  to  the  fungoid  parasite  Claviceps  purpurea,  which  infests 
n."e.  wheat,  and  other  food  products  raised  on  new  more  frequently 
than  those  grown  on  old  ground,  or  soil  which  has  undergone  culti- 
vation for  a  considerable  time.  Ergotismus  may  produce  abdominal 
cramps,  tingling  of  the  extremities,  convulsions,  delirium,  other 
evidences  of  a  profoundly  disturbed  nervous  system  or  dr\-  gangrene, 
and  in  exceptional  cases  it  produces  diarrhea. 

Maidismus,  or  pellagra,  is  a  disturbance  of  metabolism  frequently 
encountered  in  Lombardy.  Spain,  and  our  Southern  States,  where 
corn  bread  constitutes  a  regular  and  important  part  of  the  daily 
diet.  The  disease  is  thought  to  be  due  to  bacteria  or,  more  likeh", 
to  their  toxins,  which  contaminate  the  meal  from  which  bread  is 
made,  a  food  stuff  easily  infected  when  left  exposed  to  the  air,  or  when 
kept  in  a  damp  cellar  or  room.  Repeated  eating  of  bread  made  from 
spoiled  meal  may  sooner  or  later  lead  to  pronounced  chronic  nutri- 
tional disturbances,  indicated  by  loss  of  appetite,  imperfect  digestion, 
bodily  weakness,  tired  feeling,  and  frequently  diarrhea.  Here  diar- 
rhea is  very-  profuse,  and  the  trouble  appears  to  be  rather  the  effect 
of  a  constitutional  toxemia  working  through  the  nervous  apparatus 
than  to  local  lesions  within  the  bowel,  although  occasionally  gastro- 
enteritis has  been  observed  in  the  later  stages,  which  are  often  com- 
plicated by  mouth,  throat,  and  skin  affections,  together  with  pares- 
thesia, headache,  and  melancholia,  and  occasionally  the  fatty  de- 
generation of  the  internal  organs. 

Lathyrismus,  or  chicken-pea  poisoning,  is  almost  unheard  of  in  this 
countn,',  and  since  this  type  of  toxemia  leads  to  paraplegia  and  other 
profound  ner\ous  disturbances,  and  seldom,  if  ever,  produces  diar- 
rhea, nothing  furtlur  need  be  said  concerning  it. 

Other  Food  Diarrheas. — In  this  connection  the  author  wishes 
to  call  attention  to  the  fact  that  food  diarrhea  is  not  always  conse- 
quent upon  poison  contained  in  the  articles  of  diet  above  mentioned, 
or  toxins  formed  within  the  body,  because  he  has  treated  many 
patients  wherein  the  diarrhea  resulted  from  gormandizing,  improper 
mastication,  eating  of  indigestible  food  stulYs,  or  those  which  left  a 


SYMPTOMS 


159 


large,  rough,  or  otherwise  irritating  residue  to  excite  peristalsis  and 
glandular  secretion. 

The  diagnosis  of  ptomain-poisoning  may  be  easy,  but  is  usually 
difficult,  because  it  is  necessary  to  exclude  poisoning  from  other 
articles  of  diet  before  the  trouble  can  be  attributed  to  the  mt^at. 
When  this  has  been  done,  the  greatest  task  remains,  \iz.,  that  of 
finding  out  whether  toxemia  was  caused  by  (a)  the  meat  from  dis- 
eased animals  (bacilli — enteritidis  or  paratyphoid);  (/;)  decayed  meat 
(bacilli — proteus  or  colon),  and  (c)  sausage-poisoning  (anaerobic 
Bacillus  botulinus).  Again,  it  is  no  easy  matter  to  differentiate  be- 
tween poisoning  resulting  from  bacteria  and  that  following  their 
toxins  formed  before  or  after  the  meat  has  entered  the  body.  From 
what  has  already  been  said,  it  may  be  inferred  that  some  idea  of  the 
nature  of  the  trouble  (ptomain-poisoning)  can  be  gained  from  a  clear 
history  of  other  cases  and  by  observing  the  symptom-complex,  but 
it  is  impossible  to  determine  the  exact  nature  of  the  disturbing  element 
except  by  means  of  bacteriologic  examination,  although  some  have 
attempted  to  do  so  by  sera.  Consequently,  it  is  important  to  quickly 
select,  prepare,  and  protect  a  portion  of  the  suspected  food  and 
immediately  send  it  to  the  laboratory  for  chemic,  microscopic,  and 
experimental  examination.  In  so  far  as  the  blood  is  concerned, 
changes  are  unimportant,  but  in  rare  instances  the  causative  agents 
are  discoverable  within  it. 

The  symptoms  of  meat-  or  ptomain-poisoning  vary  greatly,  accord- 
ing to  the  character  and  extent  of  the  infection.  In  one  instance  the 
disturbance  may  be  slight  and  of  short  duration,  and  in  another  pro- 
found, and  remain  as  a  sequel  to  disturb  the  gastro-intestinal  tract 
for  a  considerable  time,  or  it  may  cause  death  anywhere  in  from  four 
to  ten  days. 

The  phenomena  iollowing  bacterial  activity  appear  a  few  hours 
after  ingestion,  and  while  similar  in  some  respects  in  all  cases,  neces- 
sarily vary  according  to  the  type,  amount,  and  virulence  of  the 
toxin  or  inciting  bacteria.  The  gastro-intestinal  tract  is  usually  slightly 
or  profoundly  disturbed  in  all  cases,  but  in  Bacillus  botulinus,  or 
sausage-poisoning,  the  nervous  system  is  affected  to  a  much  greater 
extent  than  in  the  other  types  of  meat  toxemias.  Unimportant 
attacks  are  usually  of  short  duration,  and  the  patient  recovers  wnthin 
a  week  or  ten  days,  but  when  he  is  profoundly  poisoned,  acute  mani- 
festations may  last  a  short  time,  be  subacute  for  weeks,  become 
chronic,  or  continue  through  life. 

The  mildest  form  of  ptomain-poisoning  is  accompanied  b\-  nausea, 
vomiting,  anorexia,  dizziness,  blanching  of  the  skin,  which  fre- 
quently has  a  greenish  hue,  elevated  or  subnormal  temperature, 
cold  perspiration,  marked  muscular  weakness,  mild  or  severe  ab- 
dominal pain,  bursting  occipital  headache,  restlessness,  explosive 
diarrhea,  and  yellow  and  offensive  stools. 

Again,  when  toxemia  is  more  pronounced,  the  attack  closely  re- 
sembles that  of  cholera,  in  so  far  as  vomiting,  purging,  and  colorless, 


l60  TOXIC    DIARRHEA 

waten.-  evacuations  (fifteen  to  twenty  the  first  day)  are  concerned,  and 
the  patient  suffers  from  thirst,  a  subnormal  temperature,  livid  skin, 
fast  pulse,  cramps  in  the  abdomen  and  legs,  depression,  dimness  of 
vision,  difficult  breathing,  coated  tongue,  buccal  soreness,  lassitude, 
retention  of  urine,  and  sometimes  icterus,  convulsions,  paralysis, 
or  collapse. 

The  symptoms  enumerated  rather  indicate  that  bacterial  products 
(toxins)  are  responsible  for  the  poisoning,  but  when  the  disturbance 
begins  with  a  chill,  followed  by  a  rapid  rise  of  temperature  (which 
continues  irregular  or  elevated  for  several  days),  and  the  condition 
of  the  patient  assumes  a  typJwid-Iike  character  (pea-soup-like  stools), 
bacterial  infection  is  considered  to  be  the  exciting  cause  of  the  gastro- 
intestinal and  other  manifestations  of  the  poisoning. 

The  abdomen  is  usually  tender  or  painful  on  pressure,  generally 
distended,  but  in  rare  instances  retracted,  the  liver  is  sometimes  and 
the  spleen  frequently  enlarged  and  palpable  after  the  second  day. 
and  albumin,  which  is  occasionally  abundant  in  the  urine,  gradually 
subsides  with  the  attack,  as  does  hematuria. 

Huebener  has  called  attention  to  the  fact  that  the  urine  often 
contains  the  pathogenic  agents  at  an  early  date  (Bacillus  enteritidis, 
Gartner  group,  and  paratyphoid  bacillus  group).  In  protracted  cases 
long-continued  bacteriuria  and  chronic  cystitis  may  develop. 

Er\-thema,  urticaria,  hemorrhagic  spots,  and  other  superficial 
cutaneous  disturbances  are  frequent  complications,  and  Leutz  has 
pointed  out  that  herpes  labialis  is  a  characteristic  manifestation 
in  meat-poisoning  due  to  paratyphoid  infection. 

The  symptoms  of  hotuUsr}!,  or  sausage-poisoning,  require  separate 
consideration,  because  here  obstinate  constipation  prevails  more  often 
than  diarrhea,  and  further,  because  they  differ  markedly  in  some 
ways  from  those  of  other  meat  toxemias.  Patients  afflicted  with 
botulism  may  suffer  from  minor  gastro-intestinal  disturbances,  but 
their  nenvus  and  secretory  systems  are  always  greatly  impaired, 
and  the  consequent  manifestations  resemble  those  of  belladonna- 
poisoning  (ocular  disturbances,  dysphagia,  aphonia,  and  dr\-ness  of 
the  mouth  and  throat,  due  to  deficient  salivar\-  secretion  or  retention 
of  urine). 

In  the  412  cases  of  sausage-poisoning  collected  by  Senkpiel  there 
was  a  mortality  of  40  per  cent. 

The  author  has  treated  a  great  many  patients  for  chronic  diar- 
rhea who  have  formerly  suffered  from  food-  or  ptomain-poisoning. 
The  loose  movements  in  this  class  of  sufferers  were  traceable  to  an 
irritable  or  inflamed  gastro-intestinal  mucosa  in  the  majority  of  cases, 
but  in  some  it  was  ascribed  to  the  neurotic  condition  in  which  the 
patient  was  left.  Owing  to  the  nervous  state  of  the  patient  and 
irritable  condition  of  the  stomach  and  bowel,  attacks  of  indigestion 
and  diarrhea  were  frequently  brought  on  by  psychic  disturbances 
(fright,  grief,  worn.'),  indiscretions  in  diet,  and  exposure. 

In    addition    to    impaired    digestion    and    loose    movements,    his 


TREATMENT  l6l 

patients,  while  undergoing  a  long  convalescence  (especially  elderly 
and  persons  ha\'ing  little  resistance),  have  often  suffered  from  general 
and  cardiac  weakness,  anorexia,  headaches,  anemia,  and  nervous 
phenomena  which  made  them  easy  victims  to  infectious  diseases. 

Death  most  often  occurs  within  twenty-four  hours,  but  has  been 
known  to  superxene  three  weeks  or  longer  afterward,  and  the  mor- 
tality from  poisoning  ma\'  be  high  or  low  according  to  the  type  of  and 
amount  of  poison  consumed.  In  some  epidemics  a  large  number  of 
individuals  have  died,  while  others  have  had  narrow  escapes. 

The  symptoms  of  fish-,  oyster-,  crab-,  mussel-,  and  snail-poisoning 
resemble  each  other,  but  the  manifestations  of  fish-poisoning  come 
on  usually  several  hours  after  eating,  while  those  of  oysters  and  crabs 
appear  in  two  or  three  hours  or  sooner,  but  toxemia  frcjm  mussels  is 
indicated  within  from  fifteen  to  thirty  minutes. 

In  mild  cases  of  fish-  or  shell-fish-poisoning  the  patient  com- 
plains of  nothing  more  than  slight  nausea,  vomiting,  diarrhea,  diz- 
ziness, and  headache;  these  symptoms  gradually  recede,  and  he 
entirely  recovers  within  two  or  three  days.  In  more  aggravated 
cases,  in  addition,  the  peitient  complains  of  throat  dryness  or  con- 
striction, weakness,  rapid  pulse,  difficult  respiration  and  aggra- 
vated gastro-enteritis,  evidenced  by  persistent  nausea,  vomiting, 
erythema,  urticaria,  or  swelling  of  the  skin,  and  exhaustive  frequent 
movements,  which  cause  rectal  tenesmus  and  contain  considerable 
blood  and  mucus.  Besides  these  manifestations  in  extremely  severe 
(jr  fatal  cases,  the  patient  may  also  suffer  from  d\spnea,  delirium, 
coma,  and  complete  collapse. 

Patients  afflicted  with  crab-  c^r  mussel-poisoning  may  also  suft'er 
from  hematuria,  convulsions,  a  mild  form  di  paralysis,  and  severe  di- 
arrhea or  ol)stinate  constipation. 

The  treatment  of  the  various  forms  of  food-poisoning  will  be  dis- 
cussed together,  because,  in  a  large  measure,  the  prophylactic,  symp- 
tomatic, and  curati\"e  therapeutic  measures  in  all  are  very  much  the 
same. 

Prophylaxis  consists  in  selecting  healthy  meat,  milk,  and  other 
foods,  in  protecting  them  from  the  air  and  keeping  them  in  a  dry 
cold  place,  in  partaking  of  cooked  in  preference  to  raw  foods,  and 
having  all  animals  and  meats  thoroughly  inspected,  requiring  that 
all  vegetables  and  food  products  should  be  under  supervision  while 
being  chosen  and  canned,  prohibiting  the  eating  of  food  stuffs  which 
have  been  exposed  to  the  air  sufficiently  long  for  putrefaction  to 
begin,  and,  above  all,  to  see  that  refrigerators  in  the  home,  hotels,  and 
restaurants  are  thoroughly  cleaned  daily,  and  that  old  or  undesirable 
fish,  meat,  shell-fish,  and  other  articles  of  diet  which  may  be  diseased 
do  not  come  in  contact  with  fresh  supplies. 

The  treatment  is  largely  symptomatic,  since  specific  antidotes  to 
the  various  poisons  have  not  been  discovered.  When  urgent  toxic 
symptoms  manifest  themselves  while  drinking  milk  or  eating,  or 
immediately  thereafter,  the  stomach  should  be  washed  out,  or  ipecac. 


1 62  TOXIC    DIARRHEA 

mustard,  apomorphin,  or  other  reliable  emetic  should  be  adminis- 
tered to  evacuate  the  poison  and  relieve  present  and  prevent  future 
distress.  When  the  patient  is  seen  at  a  later  time,  after  the  toxin 
has  passed  into  the  bowel,  gastric  lavage  should  be  instituted  for  the 
patient's  comfort,  and  castor  oil,  calomel,  or  a  saline  cathartic  should 
be  administered  to  free  the  bowel  of  its  irritant  contents,  this  to  be 
followed  by  copious  high  colonic  irrigation.  Slippery-elm  water, 
flaxseed-tea,  mucilaginous  drinks,  and  sedatives  like  charcoal,  magne- 
sium, and  bismuth  should  be  administered  in  liberal  amounts  to  relieve 
gastro-intestinal  irritation  after  elimination  of  the  poison.  When 
the  sulTerer  is  exhausted  from  prolonged  nausea,  vomiting,  and 
purging,  he  should  be  strengthened  by  strychnin,  digitalis,  whisky 
or  brandy  by  mouth  or  hypodermically,  and  if  in  great  pain,  hot 
applications  should  be  applied  over  the  abdomen  to  soothe  the  bowel 
and  relieve  cramps.  It  frequently  becomes  necessary  to  prescribe 
remedies  to  relieve  the  diarrhea,  and  for  this  there  is  nothing  better 
than  morphin  or  opium,  gr.  ^  (0.03),  combined  with  the  extract  of 
belladonna,  gr.  J  (0.015),  adding  calomel,  salol,  or  beta-naphthol, 
gr.  X  (0.60),  three  times  daily,  when  an  antiseptic  is  indicated  to 
minimize  putrefactive  changes.  When  the  patient  is  profoundly  ill 
an  ice-bag  should  be  applied  to  the  head  and  subcutaneous  salt  in- 
fusion practised.  Where  the  condition  takes  on  a  typhoid  character 
(as  frequently  in  botulism)  the  treatment  is  about  the  same  as  for 
typhoid  fever. 

In  aggravated  cases,  where  the  gastro-intestinal  mucosa  is  left 
chronically  inflamed,  remedies  used  in  the  treatment  of  gastro-intes- 
tinal catarrh,  described  elsewhere,  are  indicated.  Many  individuals 
who  have  undergone  meat-  and  other  types  of  food-poisoning  are  fre- 
quently left  in  an  extremely  nervous  state  and  otherwise  run  down,  and 
it  is  advisable  to  have  them  change  their  environments,  live  a  free, 
happy  life  in  the  open  air,  and  take  a  tonic  until  such  time  as  they 
are  restored  to  their  former  health. 

The  treatment  of  mushroom  {muscann)  poisoning  is  obviously 
symptomatic,  and  consists  in  washing  out  or  emptying  the  stomach 
with  emetics,  prescribing  a  cathartic  to  free  the  intestine  of  the  poison, 
the  administration  of  stimulants,  and  giving  atropin  alone  or  in  com- 
bination with  morphin  to  counteract  the  toxic  effect  of  the  muscarin 
and  to  relieve  colic  and  diminish  the  number  of  evacuations. 

The  treatment  of  maidismus  (pellagra),  or  grain-poisoning,  is  largely 
prophylactic,  and  consists  in  seeing  that  precautions  are  taken  that 
grain  used  for  food  purposes  is  pure,  and  that  the  meal  from  it  is 
neither  left  exposed  nor  where  it  can  accumulate  moisture,  which 
causes  it  to  ferment  and  putrefy.  For  those  afflicted,  supportive 
measures  should  be  instituted,  and  antidiarrheal  remedies,  etc., 
prescribed  to  control  loose  movements  and  relieve  other  unpleasant 
symptoms. 


CHAPTER   XIV 

TOXIC  DIARRHEA  (Concluded) 
MEDICINAL-CHEMICAL  POISONING 

There  is  a  long  list  of  medicines  and  chemical  agents  which,  when 
introduced  into  the  body  by  mouth,  through  the  anus,  by  inunction, 
subcutaneously,  or  inhalation,  incite  acute  or  chronic  diarrhea  through 
their  effect  upon  the  local  or  distant  nerve-centers  by  entering  the 
blood,  and  later  being  excreted  into  the  intestine,  and  most  frequently 
because  of  their  direct  irritating  action  upon  the  mucosa,  which  sets 
up  a  catarrh  of  the  stomach,  small  intestine,  or  colon;  or  a  gastro- 
enterocolitis  wherein  the  mucous  membrane  is  congested,  eroded,  or 
ulcerated.  Of  these  numerous  etiologic  factors,  the  writer  will  discuss 
only  those  which  are  most  often  responsible  for  the  more  chronic 
types  of  diarrhea,  since  the  others  are  apt  to  terminate  fatally,  or 
when  the  patient  recovers  the  intestinal  manifestations  are  inclined 
to  subside  quickly. 

In  discussing  the  relation  of  inorganic  poisons  to  diarrhea,  nothing 
will  be  said  concerning  the  diagnosis  except  what  is  stated  here,  be- 
cause it  depends  largely  upon  getting  the  histor\-  of  the  case  and 
determining  if  the  patient  has  taken  a  drug,  and,  if  so,  the  amount 
and  kind.  In  addition,  it  is  important  to  study  the  symptom-com- 
plex carefully,  because  certain  poisons  develop  characteristic  mani- 
festations. Finally,  it  may  be  stated  that  information  as  to  the 
nature  of  the  poison  can  in  some  instances  be  obtained  by  inspecting 
the  mouth  for  burns  and  discolorations,  and  by  making  chemic, 
macroscopic,  and  microscopic  examinations  of  the  stomach  contents, 
feces,  urine,  and  blood,  but  these  diagnostic  measures  are  of  but  com- 
parativeK'  little  value. 

Arsenic-poisoning,  Diarrhea  of. — Here  the  poison  may  gain  en- 
trance through  being  taken  deliberately  for  suicidal  purposes  or 
through  habit  in  neurotic  individuals;  accidentally  by  inhalation  or 
absorption,  in  arsenic  miners  and  artificial  flower,  shot,  glass,  paper, 
and  analine  dye  makers,  taxidermists,  and  by  women  who  take  it 
internally  or  rub  it  in  the  skin  to  improve  the  complexion. 

One  of  the  most  frequent  and  distressing  manifestations  of  acute 
or  subacute  arsenic-poisoning  is  disturbance  to  the  gastro-intestinal 
tract,  the  nature  of  which  depends  upon  the  amount  taken  at  one  time 
and  the  accumulative  quantity  present  in  the  system,  w^here  the  drug 
has  been  taken  in  liberal  amounts  for  a  considerable  time.  Persons 
suddenly  becoming  poisoned  from  this  agent  suffer  dizziness,  nausea, 
vomiting,  headache,  weakness,  twitching,  puffy  eyelids,  epigastric  pain, 

163 


164  TOXIC    DIARRHEA 

distressing  thirst,  and  freciucnt  rice-water  evacuations  (resembling 
choleriform  stools),  manifestations  which  appear  in  from  a  half-hour 
to  six  hours  following  ingestion  of  the  poison,  gradually  increase  in 
severity,  and  often  terminate  fatally  wnthin  one  or  two  days  in  un- 
treated or  improperly  handled  cases.  Other  symptoms  of  this  and 
the  chronic  form  of  arsenic-poisoning  are  irritation  of  the  respiratory 
tract,  skin  eruption,  hematuria,  albuminuria,  cardiac  weakness,  mul- 
tiple neuritis,  muscular  spasm,  and  tenesmus  following  the  frequent, 
exhausting,  fluid  evacuations. 

The  difl^use  debilitating  dysenteriform-like  diarrhea  encountered 
in  arsenic-poisoning  is  attributable  to  the  direct  irritating  action  of 
the  drug  upon  the  mucosa  (which  results  in  active  gastro-enterocolitis) 
and  effect  of  the  poison  upon  the  general  and  local  intestinal  nervous 
mechanism,  and,  finally,  in  chronic  aggravated  cases,  to  fatty  degen- 
eration of  the  intestinal  musculature. 

Autopsy  findings  show  the  intestine  relaxed,  containing  mucus  and 
pasty  or  less  often  fluid  feces,  and  the  serosa  inflamed  and  mucosa 
congested  or  excoriated.  Hemorrhagic  infarcts  variable  in  number 
are  at  times  observed  in  the  edematous  mucosa,  with  enlargement  of 
the  solitary  and  conglomerate  follicles,  and  occasionally  ulcers  wath  a 
hemorrhagic  base. 

Treatment. — The  essentials  in  the  treatment  of  diarrhea  conse- 
quent upon  arsenic-poisoning  consist  in  (a)  stopping  its  administra- 
tion and  use  and  changing  the  vocation  of  patients  who  work  in  it;  (b) 
instituting  measures  which  will  eliminate  it  from  the  system;  and, 
finally,  (c)  treating  the  gastro-intestinal  catarrh  induced  by  it. 

In  acute  arsenic-poisoning,  where  the  patient  is  seen  shortly  after 
taking  the  drug,  repeated  gastric  and  intestinal  lavage  with  hot  water 
or  medicated  solutions  add  greatly  to  the  patient's  comfort  and 
minimizes  toxic  manifestations  by  dislodging  and  washing  out  the 
poison  and  soothing  the  irritated  gastro-intestinal  tract.  When  this 
is  not  feasible,  or  lavage  fails  to  accomplish  the  desired  result,  emetics 
should  be  tried,  but  when  marked  toxic  symptoms  still  prevail,  an  iron 
preparation  is  indicated,  the  most  generally  used  of  which  is  the 
compound  of  magnesia  and  iron  hydrate  in  tablespoonful  doses 
every  fifteen  to  forty  minutes  until  the  patient  is  relieved. 

Here  we  are  more  particularly  interested  in  chronic  arsenic-poison- 
ing, for  the  reason  that  it  is  most  often  the  inciting  factor  in  diarrhea. 
In  this  class  of  cases  the  treatment  should  be  supportive,  sympto- 
matic, and  directed  against  gastro-intestinal  irritation  and  catarrh, 
along  with  preventing  further  entrance  of  the  drug  into  the  body  and 
in  eliminating  it  from  the  system  as  speedily  as  possible  by  the  internal 
administration  of  potassium  iodid,  stimulating  the  emunctories,  and 
subjecting  the  patient  to  hot  baths  and  friction  massage.  Local 
treatment  of  the  bowel  consists  in  the  internal  administration  of 
opium  and  astringent  and  antiseptic  agents  to  relieve  pain,  quiet 
peristalsis  and  soothe  the  inflamed  mucosa,  and  in  frequently  irrigating 
the  bowel  with  mild  solutions  of  boric  acid,  ichthyol,  salts,  or  oils. 


MERCURIAL    POISONING,    DIARRHEA    OF  1 65 

Mercurial  Poisoning,  Diarrhea  of. — Diarrhea  from  acute  mer- 
curial poisoning  requires  slight  attention,  except  when  the  patient 
recovers  and  it  is  a  sequel,  because  it  constitutes  one  of  the  minor 
manifestations  observable  after  the  swallowing  of  bichlorid  tablets 
(or  other  forms  of  mercury)  accidentally  or  with  suicidal  intent. 
For  the  immediate  relief  of  this  class  of  sufferers  the  stomach  should 
be  washed  out,  they  should  be  surrounded  with  hot-water  bottles, 
and  given  an  opiate  to  relieve  pain,  stimulants  to  brace  them  up,  and 
white  of  eggs  and  other  albuminous  substances  to  combine  with  the 
mercurial  salt  and  minimize  its  action.  Later,  because  of  the  gastro- 
enteritis, the  patient  should  be  kept  for  a  short  time  upon  a  fluid  or 
non-irritating  diet. 

The  ph\sician  is  most  frequently  called  upon  to  treat  gastro-in- 
testinal  manifestations  arising  from  chronic  mercurial  poisoning  that 
are  the  sequeke  of  acute  poisoning,  and  mercurialism  resulting  from 
the  unavoidable  inhalation  of  the  chemical  1)\"  miners,  smelters,  and 
persons  engaged  in  making  mirrors,  thermometers,  felt  hats,  and 
vermilion  pigment,  or  its  absorption  through  the  skin  by  contact  when 
prescribed  in  the  form  of  medication,  for  at  the  proper  temperature 
the  agent  is  volatile  and  readily  finds  its  way  into  the  blood  through 
the  avenue  mentioned.  Consequently,  when  it  regularly  enters  the 
system  for  a  considerable  time  it  disturbs  the  stomach  and  intestine 
locally,  and  through  its  effect  upon  the  general  and  nervous  sys- 
tems causes  an  aggravated  type  of  diarrhea,  as  is  evidenced  by  ane- 
mia, emaciation,  foul  breath,  muscular  weakness,  falling  out  of  the 
hair,  brittleness  of  the  nails,  metallic  taste,  salivation,  stomatitis, 
buccal  ulcers,  nausea  and  vomiting,  inflammation  of  the  stomach,  and 
pronounced  enterocolitis  fwith  and  without  ulcers). 

Almkvist  believes  that  in  mercurial  colitis  and  stomatitis  the 
mucosa  of  the  colon  and  of  the  buccal  ca\"ity  becomes  loosened  or 
eroded  as  the  result  of  local  putrefactive  changes,  and  that  the 
hydrogen  sulphid  gas  formed  by  these  processes  is  in  part  reabsorbed. 
When  the  blood  contains  mercur\-  a  deposit  of  sulphur  and  mercury- 
appears  in  the  superficial  capillaries  and  finds  its  way  into  the  endo- 
thelial cells  of  the  vessel  walls,  and  leads  to  disturbances  in  the  cir- 
culation and  nutrition.  The  organism  endea\ors  to  remove  the  deposit 
of  mercur>^  from  the  vascular  walls  through  the  leukocytes;  hence, 
in  long-standing  cases  abundant  granules  of  mercury  are  found  in 
the  leukocytes.  When  the  deposit  is  considerable,  and  cannot  be 
removed  by  the  leukocytes,  necrosis  of  the  tissue  follows. 

The  treatment  is  exident,  and  consists  in  discontinuing  mercurial 
preparations  and  in  changing  the  occupation  of  the  patient,  so  that 
he  may  not  be  compelled  to  inhale  or  absorb  the  mineral.  Much 
comfort  is  to  be  had  from  frequent  rinsing  with  a  mouth-wash  contain- 
ing the  chlorate  of  potassium  and  myrrh  or  antiseptic  and  astringent 
solutions,  occasional  gastric  lavage,  mild  non-irritating  diet,  sulphur 
baths,  and  liberal  doses  of  potassium  iodid,  which  help  to  eliminate 
the  mercur>^     In  addition  to  this,  a  supportive  treatment  should  be 


1 66  TOXIC    DIARRHEA 

instituted  and  the  intestine  should  receive  attention  through  the 
administration  of  bismuth,  tannalbin,  or  ichthalbin  in  5-gr.  (0.30) 
doses  four  times  daily,  to  lessen  the  secretions  and  heal  the  inflamed 
or  ulcerated  mucosa,  along  with  beta-naphthol,  salol,  and  other  anti- 
septic remedies  when  there  are  pronounced  fermentative  or  putrefac- 
tive disturbances.  This  treatment  should  be  reinforced  by  daily  or 
triweekly  high  colonic  irrigations,  using  weak  or  strong  solutions 
(according  to  indications)  of  silver  nitrate,  boric  acid,  formalin,  ich- 
thyol,  krameria,  and  soda  or  salicylic  acid,  to  remove  the  toxins, 
debris,  mucus,  and  fecal  accumulations  and  to  clean  and  stimulate 
healing  of  the  inflamed  or  ulcerated  mucosa. 

Lead-poisoning,  Diarrhea  of. — Lead-poisoning  is  fairly  common 
among  painters,  plumbers,  and  persons  who  mine  or  make  sheet-lead 
or  shot.  Lead,  when  consumed  with  the  food,  drinking  water  from 
lead-lined  cisterns  or  pipes,  and  as  lead  chromate  used  to  give  the 
yellow  color  to  certain  articles  of  diet,  such  as  butter,  candy,  etc., 
may  produce  plumbism.  This  mineral  passes  through  the  skin  with 
difticulty,  is  readily  absorbed  through  the  gastro-intestinal  tract  and 
lung,  and  is  chiefly  eliminated  through  the  kidneys.  It  is  not  neces- 
sary to  enumerate  the  usual  familiar  symptoms  of  lead-poisoning 
further  than  those  which  relate  to  the  gastro-intestinal  tract.  These 
patients  usually  complain  of  lead-colic  or  pains  radiating  from  the 
central  abdomen,  marked  constipation,  but  in  rare  instances  they 
suffer  from  an  aggravating  diarrhea  alone  or  alternating  with  con- 
stipation. The  diagnosis  is  usually  easy,  and  the  treatment  is  simple, 
and  consists  in  forestalling  the  further  consumption  or  absorption  of 
lead,  the  administration  of  opium  or  morphin,  gr.  |  to  |  (0.008-0.015), 
in  combination  with  belladonna,  gr.  \  (0.008),  to  relieve  pain,  cramps, 
hypersecretion,  abnormal  peristalsis,  and  in  this  way  control  the  diar- 
rhea, and,  where  constipation  prevails  or  alternates  with  the  fre- 
quent movements,  a  laxative,  such  as  salts  or  castor  oil,  is  indicated  to 
procure  the  daily  e\acuations  and  prevent  fecal  impaction,  a  not 
infrequent  complication  of  plumbism. 

Phosphorus-poisoning,  Diarrhea  of. — Phosphorus-poisoning  ex- 
cites nausea,  \omiting.  pain  in  the  hepatic  and  epigastric  regions, 
jaundice,  hematuria,  intestinal  hemorrhage,  and.  in  rare  instances, 
diarrhea,  and  is  characterized  by  ecchymoses  in  the  serous  and  mucous 
membranes,  kidneys,  and  elsewhere. 

Briefly  stated,  the  treatment  consists  in  gastro-intestinal  lavage 
(with  a  weak  potassium  permanganate  solution),  employing  emetics, 
administering  mucilaginous  drinks,  and  prescribing  opiates  to  control 
pain  and  diarrhea,  and  laxatives  when  constipation  is  troublesome. 

Acid  Poisoning,  Diarrhea  of. — The  manifestations  of  and  the 
manner  in  which  mineral  and  organic  acids — hydrochloric,  nitric, 
nitrous,  sulphuric,  sulphurous,  oxalic,  tartaric,  acetic,  and  carbolic 
— produce  diarrhea  so  closely  resemble  each  other  that  their  sep- 
arate discussion  is  unnecessary.  The  disturbance  incident  to  them 
is  usually  acute,  though  occasionally  chronic  gastro-intestinal  irrita- 


ALKALI-POISONING,    DIARRHEA    OF  167 

tion  remains  as  a  sequel  to  these  poisons,  which  are  taken  acci- 
dentally, with  suicidal  intent,  or  administered  in  mistaken  dosage  or 
erroneously  for  some  other  drug.  The  most  intense  suffering  here 
results  from  burns  in  the  mouth,  throat,  esophagus,  and  stomach, 
which  may  remain  superficial  or  lead  to  extensive  necrosis  and  ulcera- 
tion, followed  by  stricture.  Under  such  circumstances  swallowing  is 
painful,  the  patient  complains  of  a  choking  sensation,  profuse  saliva- 
tion, and  distention  of  the  abdomen,  which  is  tender  upon  pressure. 
There  is  an  increased  frequency  of  the  evacuations,  which,  because  of 
their  bloody  character,  resemble  those  of  colitis  and  other  inflamma- 
tory and  ulcerative  lesions  of  the  small  bowel  or  colon. 

The  symptoms  of  colonic  catarrh  and  diarrhea  supposedly  result 
chiefly  from  a  loss  of  alkali  which  is  necessary  to  metabolism.  Very 
soon  after  acid  has  been  introduced  into  the  stomach  there  begins  an 
increased  acid  excretion  through  the  kidneys,  and  a  passage  of  acid 
fluid  through  the  large  intestine,  giving  rise  to  secondary  diarrhea. 
It  is  not  necessarily  the  ingested  and  absorbed  acid  itself,  which  is 
speedily  excreted,  for  the  body  gives  off  large  amounts  of  its  stored 
alkali  for  the  neutralization  of  the  ingested  acid,  and  the  excretory 
organs  endeavor  to  compensate  the  resulting  loss  of  alkali  by  elimi- 
nating considerable  quantities  of  compounds  with  an  acid  reaction 
from  the  body.     The  effect,  of  course,  is  identical. 

When  instituting  the  treatment,  if  the  patient  is  seen  immediately 
gastric  lavage  is  indicated,  but  later,  owing  to  the  danger  of  perfora- 
tion, distention  of  the  stomach  with  water  or  neutralizing  agents  is 
extremely  dangerous,  because  it  is  impossible  to  foretell  the  extent 
and  depth  of  the  eschars.  The  most  desirable  remedies  to  prescribe 
are  magnesia  (lime-water),  soap  in  liberal  doses,  or  a  few  drops  of 
liquor  sodse  in  mucilage,  to  counteract  the  escharotic  effect  of  the  acid. 

Carbolic-acid- poisoning  constitutes  the  most  frequent  of  the  above 
group,  and  the  treatment  deserves  separate  consideration,  since  it 
differs  somewhat  from  the  above.  Briefly  summed,  this  consists  in 
gastric  lavage,  using  lime-water  or  alcohol  (25  per  cent.)  liberally, 
which  is  an  antidote  to  carbolic  acid. 

When  the  patient  is  out  of  danger  from  immediate  effects  of  the 
poisoning  he  should  be  placed  upon  a  fluid  diet  or,  if  necessary,  rectal 
nutrient  enemata,  given  oil,  bismuth,  magnesia,  charcoal,  and  like 
sedative  and  soothing  agents  alone,  or  in  combination  with  anti- 
diarrheal  remedies  to  relieve  gastro-intestinal  pain  and  diminish 
diarrhea.  In  the  meantime,  stimulants  and  remedies  which  sustain 
the  system  should  Ix-  administered.  The  subsequent  treatment  of 
enteritis  and  colitis  from  carbolic-acid-poisoning  is  the  same  as  that 
recommended  elsewhere  for  the  relief  of  these  conditions  from  other 
causes. 

Alkali-poisoning,  Diarrhea  of. — The  milder  alkalies — sodium  car- 
bonate, potassium  acetate,  citrate,  carbonate,  etc. — when  administered 
in  large  doses  or  for  a  long  time  may  cause  slight  irritation  to  the 
intestinal  mucosa  and  interfere  with  digestion,  but  strong  or  caustic 


1 68  TOXIC    DIARRHEA 

alkalies — calcium  (slaked  lime),  calcium  oxid  (quicklime),  potassium 
hydrate  (caustic  potash),  sodium  hydrate  (caustic  soda),  ammonia, 
and  lye — accidentally  or  deliberately  swallowed  are  frequently  the 
cause  of  severe  diarrhea.  Of  these,  lye-poisoning  is  most  common, 
particularly  among  children,  because  it  is  generally  used  for  scrubbing, 
and  is  often  left  around,  so  that  they  can  readily  get  hold  of  and  swal- 
low it. 

The  immediate  manifestations  of  caustic  alkali-poisoning  is  severe 
burning  pain  from  the  mouth  to  the  stomach,  difficult  sw^allowing, 
esophageal  spasms,  loss  of  voice,  salivation,  irritative  cough,  severe 
vomiting,  expectoration  of  bloody  mucus  and  shreds  of  the  mucosa, 
colic,  which  is  closely  followed  by  diarrhea,  and  there  may  be  respira- 
tory disturbances,  muscular  spasms,  disturbed  action  of  the  liver 
and  kidneys,  and  a  severe  gastro-enteritis  may  prevail  after  the  patient 
has  recovered  from  the  poison. 

The  treatment,  when  the  patient  is  seen  immediately  or  soon  after 
taking  the  caustic,  consists  in  having  him  drink  freely  of  a  weak  solu- 
tion of  vinegar,  dilute  acids  or  lemon-juice,  or  wash  out  the  stomach 
with  these  agents  to  neutralize  or  evacuate  the  poison.  In  addition, 
demulcents — milk,  flour,  water,  and  oils — should  be  administered  to 
protect  the  raw  mucosa,  along  with  opium  or  morphin  in  combina- 
tion with  atropin,  to  relieve  pain  and  visceral  spasms. 

In  aggravated  cases  where,  because  of  spasm  or  edema  of  the 
glottis,  breathing  is  difficult  or  impossible,  immediate  tracheotomy  is 
indicated. 

Fluid  and  soft  nourishment  is  permissible  when  the  patient  can 
swallow  and  digest  them,  but  frequently,  owing  to  the  raw  condition 
of  the  throat,  esophagus,  and  stomach,  this  is  impossible,  and  he  must 
be  sustained  by  frequent  nutrient  enemata.  Later,  bismuth,  chalk, 
charcoal,  tannalbin,  ichthoform,  and  beta-naphthol,  gr.  v  to  x  (0.30- 
0.60),  should  be  prescribed  three  or  four  times  daily  because  of  their 
soothing,  astringent,  antiseptic,  or  healing  action  upon  the  stomach 
and  bowel,  and  tendency  to  restrict  the  number  of  evacuations. 
Because  of  the  necessity  of  continuing  the  treatment  for  a  long  time 
it  is  not  advisable  to  permit  the  sufferers  to  take  opiates,  because  they 
may  become  habitues  to  the  drug,  yet  it  is  urgent  that  something  should 
be  done  to  allay  the  severe  gastric  and  intestinal  pains,  and  for  this 
purpose  the  author  knows  of  no  more  reliable  local  analgesics  than 
aspirin,  orthoform,  and  analgin,  gr.  v  (0.30),  administered  according 
to  indications. 

When  there  is  colitis,  with  and  without  ulceration,  colonic  irriga- 
tion with  ichthyol,  balsam  of  Peru,  or  boric  acid  (i  to  2  per  cent.)  to 
heal  the  bowel,  alternating  with  oil,  w'hich  has  a  soothing  effect  upon 
the  mucosa,  are  to  be  recommended  in  connection  with  the  above 
treatment,  and  continued  unless  the  intestinal  manifestations  subside. 

Miscellaneous  Medicinal  and  Chemical  Poisons,  Diarrhea  of. — 
In  addition  to  the  above  poisons,  there  are  numerous  medicinal  and 
chemical  agents  which,  when  taken  in  large  amounts,  accidentally  or 


MISCELLANEOUS  MEDICINAL  AND  CHEMICAL  POISONS,  DIARRHEA  OF    1 69 

purposely,  gain  entrance  into  the  circulation  in  other  ways,  produce 
diarrheal  manifestations,  slight  or  grave,  but  in  practically  all  cases 
the  increased  frcxiuency  of  the  evacuations  results  from  an  acute  or 
chronic  gastro-enterocolitis  induced  directly  or  indirectly  by  the 
poison.  Because  of  their  relatively  slight  importance  to  the  subject 
their  individual  symptomatology  and  diagnostic  features  will  be 
omitted,  and  the  author  will  simply  name  them  and  give  their  antidotes 
in  parentheses.     The  poisons  included  in  this  list  are: 

Turpentine  {magnesium  sulphate  and  emulcents). 

Cantharides  {demulcents,  saline  cathartics,  and  opium;  oils  and  fats 
interdicted) . 

Physostigmin  (fixed  alkalies  and  atropin  hypodermically). 

Pilocarpi}!  {atropin  and  morphin  hypodermically). 

Colchicum  {opium  and  astringents). 

Digitalis  {aconite,  nitroglycerin,  and  opium). 

Ergot  {stimulation  and  general  application  of  heat). 

Silver  salts  (table  salt,  demulcents,  and  milk). 

Nicotin  {restrict  tobacco). 

Conium  {emetics,  tannic  acid). 

Lobelia  (tannic  acid,  lavage,  and  stimulants). 

lodin  {starch  or  arrow-root) . 

Zinc  salts  {white  of  egg,  demulcents,  and  sodium  carbonate). 

Copper  salts  (demulcents  and  albumins). 

In  addition  to  the  administration  of  the  above  antidotes,  it  is 
frequently  necessar\'  to  resort  to  immediate  lavage,  prescribe  stimu- 
lants and  supportive  remedies,  administer  an  opiate  to  relieve  pain, 
restrict  the  diet,  and  later,  when  sequehe  and  diarrhea  are  present, 
to  have  the  patient  take  internal  remedies  and  irrigate  the  bowel 
for  the  purpose  of  controlling  the  gastro-intestinal  catarrh  caused 
by  the  poison. 


CHAPTER   XV 

COMPENSATORY    DIARRHEA 

This  rather  unusual  form  of  diarrhea  is  due  to  a  disturbed  metab- 
olism and  not  to  organic  changes  in  the  bowel  or  digestive  derange- 
ments.^ It  may  be  encountered  in  a  number  of  diseases,  the  most 
frequent  of  which  are  thyroidism,  gout,  diabetes,  Bright's  and  Addi- 
son's diseases,  pellagra,  severe  injuries,  extensive  burns,  climatic  dis- 
turbances, and  certain  affections  of  the  liver.  It  occurs  when  metab- 
olism of  an  organ  is  materially  interfered  with  through  organic  changes 
or  nervous  influence  and  there  is  an  accumulation  of  excretory  prod- 
ucts (some  toxic)  which  cannot  escape  normally,  and  hence  find  a 
means  of  exit  through  the  bowel,  to  cause  diarrhea  by  increasing  the 
fluid,  augmenting  the  secretions,  and  exciting  peristalsis. 

This  form  of  diarrhea  is  symptomatic  of  arrest  or  perversion  of 
function  of  the  skin,  lungs,  kidneys,  or  organs  of  internal  secretion, 
and  is  corrective  in  eft'ect.  The  definition  includes  those  cases  where 
the  intestinal  tract  vicariously  assumes  the  excretory  functions  of 
other  organs  or  eliminates  products  which  are  the  result  of  defective 
metabolism,  and  does  not  embrace  functional  diarrhea  when  the  intes- 
tine merely  rids  itself  of  accumulated  foreign  materials.  Stern- 
holds  there  are  three  types  of  compensatory  diarrhea,  viz.:  (i)  Diar- 
rhea concomitant  with  disturbed  catabolism.  (2)  Diarrhea  resulting 
from  disease  of  excretory  organs.  (3)  Diarrhea  occurring  during  the 
period  of  physiologic  decline. 

In  discussing  compensatory  diarrhea  Niles  has  pointed  out  that 
it  may  be  present  in  elderly  persons  undergoing  physiologic  decline, 
owing  to  incompletely  catabolized  products  which  are  not  excreted, 
and  result  from  toxic  states  where  the  toxins  are  eliminated  by  the 
intestine  as  in  the  climacteric  period. 

In  this  type  of  loose  movements  the  evacuations  are  exceedingly 
poisonous,  and  it  is  often  questionable  if  the  diarrhea  should  be  arrested, 
because  in  stopping  it  the  toxins  from  the  disease  could  not  escape 
and  would  accumulate,  to  seriously  impair  the  health  or  cause  death. 

Compensatory  diarrhea  may  lead  to  an  inflamed  or  ulcerated 
state  of  the  mucosa  and  the  loose  movements  continue  after  the 
original  cause  of  the  diarrhea  has  been  removed,  under  which  cir- 
cumstances local  treatment  of  the  bowel  is  necessary  to  efl^ect  a  cure. 

Old  Age,  Diarrhea  in. — In  old  age  the  intestinal  tract  is  the  last 
organ  to  lose  its  tonicity.     Since  the  rest  of  the  body  deteriorates, 

*  The  author  is  under  obligations  to  Dr.  Sidney  Adler  for  assistance  in  looking  up 
the  literature  of  compensatory  diarrhea. 

'  Jour.  Amer.  Med.  Assoc,  August  8,  1898. 

170 


GOUT  171 

lessening  the  activity  with  which  the  toxic  materials  are  excreted,  the 
intestine  in  a  measure  takes  up  the  work  of  the  kidneys  and  lungs,  and 
assists  in  keeping  up  the  systemic  equilibrium. 

In  old  age  there  is  a  change  in  the  kidney  and  skin  function,  and 
there  is  also  a  general  decline  of  all  the  organs  of  the  body.  Women 
more  than  men  are  subject  to  diarrhea,  and  this  is  especially  seen  at  or 
after  the  climacteric  period.  Some  of  these  women  have  never  suf- 
fered from  chronic  diarrhea  before  this  period,  but  with  the  appear- 
ance of  the  menopause  retrogressive  changes  occur,  and  the  toxic  prod- 
ucts in  the  blood  which  were  in  part  thrown  off  by  the  menstrual 
blood  must  now  find  other  means  of  egress.  The  osmotic  pressure  is 
controlled  in  women  by  the  menstrual  loss  of  blood.  After  this  is  lost 
at  the  menopause  the  hyperosmotic  blood  seeks  a  chance  to  filter 
through  the  tissue  offering  the  least  resistance,  such  as  the  intestine, 
and  the  filtrate  is  full  of  toxic  material  and  causes  diarrhea.  Some- 
times as  the  patient  grows  older  the  diarrhea  increases,  though 
structural  and  functional  changes  in  the  intestinal  wall  may  cause  it. 
People  who  perspire  freely  are  seldom  subject  to  chronic  diarrhea. 
Thevenon'  says  that  the  equilibrium  is  retained  in  elderly  persons  by 
increased  intestinal  elimination,  which  compensates  for  the  lessened 
activity  of  the  external  integument. 

Addison's  Disease,  Diarrhea  in. — The  most  common  form  of  diar- 
rhea occurring  in  this  condition  arises  at  or  toward  the  close  of  this 
affection,  and  comes  on  without  any  obvious  cause.  Retraction  of  the 
abdominal  wall  resembling  peritonitis,  colicky  pains,  with  watery  dis- 
charges, lead  quickly  to  collapse  or  delirium  and  coma.  There  is 
another  form,  owever,  which  occurs  in  the  earlier  stages  of  the  disease 
which  is  in  no  way  exhausting,  but  which  tends  to  improve  the  general 
condition.  The  disease  is  characterized  by  asthenia,  pigmentation  of 
the  skin,  general  loss  of  appetite  and  muscular  energ\-,  conditions  which 
are  improved  by  the  diarrhea. 

Diabetes. — Diabetic  coma  is  often  ushered  in  by  a  gastro-intesti- 
nal  attack.  The  diarrhea,  however,  may  be  of  a  compensatory-  nature 
and  ward  off  coma.  This  condition  would  come  earlier  and  more 
frequently  if  the  intestine  did  not  get  rid  of  the  toxins  at  the  proper 
time.  Diarrhea,  as  a  complication  of  diabetes,  may  be  due  to  the 
continued  sugar-free  diet  causing  an  intestinal  insutificiency,  or  to 
the  metabolic  processes  and  rapid  osmosis  through  the  intestinal  wall 
of  the  toxic  materials.  It  is  through  this  means  that  sugar  is  excreted 
by  the  intestine,  and  the  urine  may  become  entirely  free  from  sugar. 
After  one  of  these  attacks  the  urine  is  often  free  from  sugar,  acetone, 
and  diacetic  acid.  Sugar  is  not  always  found  in  the  feces  during 
diarrheal  attacks,  nor  is  it  found  in  the  stools  of  diabetics  whose 
bowel  action  is  normal.  In  no  other  diarrheal  condition  is  sugar 
found.  Following  the  compensatory  diarrhea  the  general  nervous 
condition  of  the  patient  also  improN'cs. 

Gout. — Gouty  individuals  (especially  obese)  are  inclined  to  con- 
1  "De  la  Diarrhee  chez  les  V^iellards,"  These  de  Paris,  1865. 


172  COMPENSATORY    DIARRHEA 

stipation.  In  cases  of  irregular  gout  the  paroxysms  are  ushered  in 
by  attacks  of  intestinal  stasis.  It  is  not  an  uncommon  occurrence 
for  these  paroxysms  to  be  entirely  prevented  by  free  bowel  move- 
ments, ridding  the  body  of  the  toxins.  The  urates  and  alloxur  bodies 
often  clog  up  the  kidneys  in  the  chronic  gouty  conditions,  seriously 
interfering  with  their  permeability;  the  intestinal  function  must  then 
take  on  the  extra  work  and  act  for  the  kidneys  too.  The  feces  in  these 
cases  contain  considerable  amounts  of  urates  and  alloxur  bases.  Clin- 
ically, we  are  able  to  demonstrate  the  compensatory  action  of  the  in- 
testine by  the  decrease  of  urine  secreted  and  the  dark  stool  of  nuclein 
substances,  tenesmus,  and  pain  felt  in  the  bowel. 

In  retrocedent  or  suppressed  gout  there  may  be  severe  gastro- 
intestinal symptoms,  pain,  vomiting,  diarrhea  and  great  depression, 
and  death  may  occur  during  one  of  these  attacks. 

Exophthalmic  Goiter,  Diarrhea  in. — Excessive  sweating  is  some- 
times seen  in  this  condition,  and  has  a  corrective  action.  In  some 
cases  diarrhea  alternates  with  the  sweating.  When  these  diarrheal 
attacks  last  longer  than  five  to  six  days  structural  changes  in  the  in- 
testine will  be  encountered.  Diarrhea  in  this  condition  lasts  but  a 
day  or  so,  and  is  always  of  a  compensatory  nature. 

Kidney  Diseases,  Diarrhea  from. — In  uremia,  where  the  function 
of  the  kidney  is  seriously  interrupted,  and  urea,  ammonium  carbonate, 
creatin,  and  creatinin  get  into  the  blood,  diarrhea  often  ensues  through 
cerebral  stimulation,  action  of  the  toxins  upon  the  intestinal  mucosa, 
vasomotor  disturbances,  peristaltic  activity,  or  transudation  of  toxic 
fluid  from  the  blood  into  the  intestine.  Where  there  are  no  uremic 
ulcers  in  the  bowel,  diarrhea  must,  of  necessity,  be  included  in  the 
body's  compensation.  When  compensatory  diarrhea  has  been  in  effect 
for  some  time  and  ulcers  are  present  the  loose  movements  may  be 
caused  by  the  lesions,  efforts  of  nature  to  protect  herself  against  toxins, 
or  both. 

Diarrhea  after  the  formation  of  uremic  ulcers  is  changed  in  effect 
and  in  regard  to  the  character  of  the  excreta.  The  occurrence  of 
an  attack  of  compensatory  diarrhea  is  an  indication  that  there  is  no 
immediate  danger  from  uremic  convulsions,  dyspnea,  or  coma.  It  is 
often  seen  in  a  uremic  condition  that  the  compensatory  diarrhea  will 
occur  more  than  once,  and  the  general  condition  of  the  patient  im- 
proves with  each  attack.  The  elimination  of  toxic  materials  by  the 
intestine  causes  congestion  and,  in  time,  erosions  of  the  mucosa,  but 
the  patient  lives  in  comparative  ease  while  the  intestinal  tract  is  caring 
for  the  elimination  of  the  renal  excreta. 

Hirschler^  has  shown  experimentally  that  ammonium  carbonate 
and  creatin  are  not  only  strong  central  intestinal  stimulants,  but 
also  peripheral  irritants.  Uremic  vomiting  is  in  the  same  class  with 
an  ulcerative  process  in  the  duodenum  or  other  portion  of  the  intes- 
tinal tract,  due  to  the  enzyme  formed  in  the  blood  causing  thrombi. 

'  Jubilar-Arbeiten   der   Schuler   Korayi's    Pester,   Medichine-Chirug.   Presse,    1891, 
No.  30. 


TREATMENT    OF    C0MPI';NSAT0RY    DIARRHEA  1 73 

Such  evacuations  arc  not  corrective  hut  path(^^enic,  and  tend  to 
weaken  an  already  exhausted  body. 

Burns,  Diarrhea  from. — When  a  considerable  portion  of  the  body 
surface  is  burned  toxic  al)sorption  symptoms  arise  through  injury  to 
the  protoplasm,  blood,  loss  of  skin  activity,  toxins,  and  shock.  Among 
the  phenomena  sooner  or  later  ojjserved  are  diarriiea,  retention  of 
urine,  delirium,  coma,  and  sometimes  a  maniacal  condition. 

In  some  cases  of  extensive  burns,  where  the  patient  is  comatose, 
pulseless,  and  respiration  is  hardly  noticeable,  diarrhea  sets  in  and  the 
general  condition  improves  at  once,  for  the  urinary  retention  disap- 
pears and  the  pulse  becomes  more  regular,  the  intestine  taking  care 
of  catabolic  elimination. 

The  treatment  of  compensatory  diarrhea  must  necessarily  vary  in 
different  cases,  and  should  be  directed  against  the  affected  part  of  the 
organism,  with  the  object  of  equalizing  metabolism,  so  that  the  harmful 
products  responsible  for  the  diarrhea  will  not  be  produced  in  abnormal 
amounts.  Where  the  movements  become  very  frequent,  offensive,  or 
exhausting,  and  the  bowel  is  inflamed  or  ulcerated,  the  intestine  should 
be  cleansed  with  medicinal  solutions  and  antidiarrheal  remedies  pre- 
scribed to  relieve  pain,  diminish  the  movements,  and  enable  the  patient 
to  obtain  rest  and  sleep. 


CHAPTER   XVI 

ENTERITIS,    COLITIS,    ENTEROCOLITIS    t NON-SPECIFIC  (?) 
INTESTINAL  CATARRH  ,  DIARRHEA  IN 

DEFINITION.   GENERAL  REMARKS,   ETIOLOGY.   PATHOLOGY 

Definition. — Inflammation  (catarrhal?)  of  the  mticosa  of  the 
small  or  large  intestines,  both  or  any  one  of  their  sections,  which, 
according  to  the  segment  or  part  of  the  bowel  involved,  is  designated 
enteritis,  duodenitis,  jejunitis,  ileitis,  colitis,  appendicitis,  typhlitis, 
sigmoiditis,  proctitis,  or  enterocolitis  when  the  entire  intestine  is 
atYected. 

General  Remarks. — The  condition  commonly  characterized  as 
enteritis,  colitis,  or  enterocolitis  constitutes  the  most  common  of  all 
intestinal  disturbances,  and  while  it  is  a  disease  that  causes  con- 
siderable annoyance,  distress,  and  often  renders  the  subject  partially 
or  completely  unfit  for  social  or  business  duties,  it  rarely  ends  fatally 
except  in  the  ver\-  young  or  old,  and  when  it  is  complicated  by  mixed 
infection  or  some  other  disease. 

Enterocolitis  is  encountered  in  all  countries,  climates,  nationali- 
ties, walks  of  life,  and  in  both  sexes,  though  it  is  more  prevalent  among 
infants  and  children  and  in  men,  particularly  those  who  are  exposed, 
than  in  others. 

The  affection  is  encountered  most  often  in  persons  between  twenty- 
five  and  forty  years  of  age,  and  may  be  acute  or  chronic,  but  is  found 
in  the  latter  form  most  frequently,  because  when  acute  it  is  either  not 
sufiiciently  distressing  to  cause  worn.'  or  the  patient  attempts  to  cure 
himself  with  home  remedies  or  patent  medicines,  and  further,  owing 
to  the  fact  that  chronic  enterocolitis  is  often  accompanied  by  diarrhea, 
colic,  digestive  disturbances,  or  other  manifestations  that  make  it 
imperative  for  the  one  afiflicted  to  seek  relief.  Owing  to  the  similarity 
of  the  symptoms  in  the  presence  of  gastric  and  enteric  or  colonic  in- 
flammation of  the  mucous  membrane,  gastritis,  enteritis,  and  colitis 
are  frequently  confused,  and  the  one  mistaken  and  treated  for  the 
other,  but  it  is  well  to  bear  in  mind  that  sometimes  the  entire  gastro- 
intestinal tract  may  be  involved  in  the  catarrhal  inflammation  (gastro- 
enterocolitis). 

Any  or  all  portions  of  the  intestinal  mucosa  may  be  involved, 
but  the  duodenum,  rectocolonic  segment,  and  ileum  are  the  sections 
most  commonly  affected.  The  first,  owing  to  its  shape  and  close  rela- 
tion to  the  stomach,  the  discharges  from  which  frequently  and  quickly 
change  the  intestinal  contents  from  an  alkaline  to  an  acid  reaction. 
The  second,  because  firm  and  nodular  feces,  gas,  and  toxins  frequently 
174 


GENERAL    RI<:MARKS  1 75 

collect  in  the  rectum  and  remain  to  irritate  the  mucous  membrane, 
and  the  third,  owing  to  the  fact  that  the  maximum  bacterial  activity 
takes  place  within  the  ileum,  which  is  conducive  to  the  catarrhal 
state. 

Colitis,  h(nvever,  is  very  much  more  common  than  enteritis,  and 
catarrhal  inflammation  is  observed  very  much  more  frecjuently  in 
the  rectum  and  sigmoid  (proctosigmoiditis)  than  in  other  portions 
of  the  large  intestine.  The  author  holds  that  catarrhal  enterocolitis 
is  not  nearly  so  common  as  is  believed  by  the  profession  generally, 
because  in  numerous  instances,  by  means  of  getting  the  history, 
going  over  the  patient  thoroughly,  and  making  a  careful  macro- 
scopic and  microscopic  examination  of  the  feces  and  discharges, 
he  has  been  able  to  demonstrate  that  patients  previously  treated 
for  this  affection  were  suffering  from  tubercular,  syphilitic,  enta- 
mebic,  balantidic,  helminthic,  coccidic,  or  ciliate  colitis;  and  in  other 
instances  he  has  been  able  to  show  that  the  bowel  disturbance  was 
due  to  a  gastrogenic,  enterogenic,  hepatogenic,  pancreatogenic  de- 
rangement, or  other  local  or  general  ailment  which  incited  diarrhea, 
colic,  or  the  discharge  of  mucus  in  the  absence  of  catarrhal  involve- 
ment of  the  gut. 

Catarrhal  enteritis  or  colitis  may  pave  the  way  for  or  be  a  sequel 
of  the  above-named  infections  and  disturbances,  or  may  complicate 
them  and  make  differentiation  of  the  one  from  the  other  extremely 
ditihcult,  hence  the  affection  may  be  either  primary  or  secondary. 
Enterocolitis  has  not  infrecjuently  been  confused  with  intestinal  can- 
cer, benign  growths,  stricture,  angulation,  twisting,  ptosis,  enteroliths, 
foreign  bodies,  or  other  lesions  or  agents  which  cause  irritation,  obstruc- 
tion, inflammation,  or  ulceration  of  the  bowel. 

Usually,  when  a  patient  complains  of  indigestion,  unduly  frecjuent 
and  loose  movements,  colic  or  abdominal  soreness  and  mucus  in  the 
dejecta,  in  the  absence  of  obvious  evidence  to  show  that  the  trouble 
is  due  to  another  infection,  a  diagnosis  of  intestinal  catarrh  is  often 
erroneously  made. 

Diarrhea  is  regarded  as  one  of  the  pathognomonic  indications  of 
catarrhal  enterocolitis,  but  many  patients  having  the  disease  do  not 
exhibit  this  symptom,  or,  if  so,  not  until  late,  but  complain  chiefly  of 
costiveness  or  constipation  alternating  with  loose  movements,  or 
sufTer  several  days  from  the  former  and  then  the  latter,  under  which 
circumstances  the  catarrhal  state  is  mistaken  for  chronic  intestinal 
obstruction.  Universal  success  in  the  treatment  of  intestinal  catarrh 
will  not  be  reached  until  physicians  realize  that  constipation  and  diar- 
rhea often  go  hand  and  glove  in  this  complaint,  and  must  be  rationally 
treated. 

Each  year  demonstrates  that  a  greater  proportion  of  patients  who 
were  formerly  thought  to  be  afflicted  with  catarrhal  enterocolitis  suft'er 
from  inflammation  of  the  mucosa,  induced  by  specific  agents,  such  as 
entamehce,  Balantidium  coli,  bacilli  (Shiga,  Flexner,  Hiss,  etc.),  coccidia, 
flagellates,  ciliates,  etc.,  which  emphasizes  the  importance  of  routine 


176  ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

fecal  examinations  in  all  cases,  so  that  ordinary  catarrhal  may  be 
differentiated  from  the  specific  infections  of  the  intestine. 

Etiology  of  Enteritis,  Colitis,  and  Enterocolitis. — The  causes  of 
enteritis,  colitis,  and  enterocolitis  are  so  numerous,  varied,  and  com- 
plicated that  to  attempt  a  detailed  explanation  of  each  would  be  futile 
in  a  work  of  this  scope;  hence,  the  author  will  be  content  with  having 
named  the  more  frequent  etiologic  factors  of  the  diseases  and  discuss- 
ing only  the  causes  of  greatest  importance. 

No  hard-and-fast  line  can  be  draw^n  which  would  clearly  separate 
the  causes  of  and  the  tissue  changes  which  take  place  in  acute  and 
chronic  inflammation  of  the  intestine,  and  because  of  this  the  etiology 
and  pathology  of  acute  and  chronic  intestinal  catarrh  (enteritis,  colitis, 
and  enterocolitis)  will  both  be  considered  together.  The  author 
will,  however,  endeavor  to  point  out  their  chief  etiologic  factors,  and 
discuss  in  logical  sequence  the  pathologic  changes  which  take  place  in 
the  bowel  during  the  acute  and  chronic  stages  of  the  disease. 

In  order  to  understand  the  etiology  and  pathology  of  this  affec- 
tion it  is  well  to  constantly  bear  in  mind  the  fact  that  enterocolitis 
may  be  primary  and  begin  independently  as  such,  or  be  secondary  to 
and  induced  by  one  or  more  of  the  local  and  general  ailments  named 
below  as  causative  factors. 

Named  in  the  order  of  their  frequency  and  importance,  the  chief 
primary  and  secondary  etiologic  factors  in  the  production  of  acute 
and  chronic  catarrh  in  the  upper  and  lower  intestines  are: 

(i)  Dietary  indiscretions  (gormandizing,  eating  at  irregular  hours, 
too  fast  or  too  often,  consuming  indigestible  foods  or  foods  too  hot  or 
cold,  that  contain  acid,  are  stimulating  or  leave  a  coarse  irritating 
residue,  and  those  which  are  unripe,  infected,  raw,  improperly  cooked 
or  partially  spoiled,  and  ice-cold  drinks  during  meals). 

(2)  Unhygienic  surroundings. 

(3)  Occupations  which  are  arduous  and  lead  to  frequent  exposure, 
etc. 

(4)  Age  (very  young,  one  to  two  years,  and  over  sixty). 

(5)  Malnutrition  (starvation,  improper  feeding,  intestinal  disturb- 
ances, etc.). 

(6)  Atmospheric  influences  (a  sudden  change  from  a  high  to  a  low 
temperature  and  vice  versa). 

(7)  Extreme  heat  (from  the  sun,  violent  exercise,  working  in  foun- 
dries, etc.). 

(8)  Impure  water  (contaminated  by  minerals,  sewage,  helminths, 
entamebse,  bacilli,  etc.). 

(9)  Sitting  in  a  draft  or  upon  cold  steps,  or  keeping  on  wet  cloth- 
ing or  shoes  which  w^ould  give  one  a  cold. 

(10)  Chronic  irritants  and  poisons  administered  in  the  form  of 
medicine,  swallowed  accidentally  or  taken  with  suicidal  intent 
(mineral  acids,  mercury,  arsenic,  cantharides,  copper,  tartar  emetic, 
spices,  pepper,  mustard,  garlic,  alcohol,  chloroform,  ether,  alkalies, 
aromatic  acids,  volatile  ethereal  oils,  etc.,  and  laxatives  and  purga- 


ETIOLOGY    OF    ENTERITIS,    COLITIS,    AND    ENTEROCOLITIS  1 77 

tives,  such  as  the  hydragogues  or  salts  and  drastic  purgatives  Hke 
senna,  jalap,  croton  oil,  and  colocynth,  which  irritate,  inflame,  or  erode 
the  mucosa). 

(11)  Chronic  irritants  of  the  blood  which  act  upon  the  mucosa  in 
the  presence  of  extensive  cutaneous  burns,  and  catarrh  of  uremic 
nephritis  and  mercurial  poison. 

(12)  Mechanical  irritants  (gall-stones,  enteroliths,  intestinal  sand, 
scybalae,  bismuth  balls,  foreign  bodies,  parched  corn,  seeds,  fruit, 
stones,  coins,  and  movable  or  ptotic  neighboring  or  distant  organs). 

(13)  Acute  and  chronic  intestinal  obstructions,  abnormalities,  and 
displacements  (malignant  and  benign  tumors,  splanchnoptosis,  ptosis 
of  the  intestine  or  other  organs,  adhesions,  extra  bowel  pressure,  stric- 
ture, angulations,  volvulus,  invagination,  strangulation,  diverticula,  or 
the  extension  of  inflammatory  processes  from  other  organs  and  struc- 
tures to  the  gut). 

(14)  Local,  general,  and  infectious  diseases  of  the  intestine  (measles, 
whooping-cough,  scarlet  fever,  diphtheria,  chicken-pox,  er>^sipelas, 
anthrax,  grip,  pneumonia,  malaria,  rheumatism,  typhoid,  ptomain- 
poisoning,  cholera,  sepsis,  and  tubercular,  syphilitic,  gonorrheal, 
entamebic,  bacillary,  balantidic,  helminthic,  flagellate,  ciliate,  or 
coccidic  colitis  (dysentery),  and  inflammatory-  states  of  the  bowel 
incident  to  the  Proteus  vulgaris,  colon  bacillus,  Bacillus  enteritidis 
(Gartner's),  sporogenes,  streptococci.  Bacillus  butyricus.  paratyphoid 
bacilli,  and  others  of  the  accidental  and  obligate  pathogenic  micro- 
organisms of  the  intestinal  canal). 

(15)  Constipation  and  fecal  impaction. 

(16)  Neuroses  and  psychic  impressions  which  influence  the  motor 
and  secretorv'  functions  of  the  intestine. 

(17)  Extension  of  inflammation  or  disease  from  other  organs  to 
the  gut  (gastritis,  appendicitis,  peritonitis,  ulcers,  cancer,  suppura- 
tive conditions,  tuberculosis,  etc.). 

(18)  Disturbances  (obstructive)  of  the  heart,  liver,  and  lungs  or 
splanchnic  circulation,  which  result  from  cachectic  states  (observed 
in  cancer,  malaria,  chronic  intestinal  auto-intoxication,  and  Bright's 
and  Addison's  diseases). 

(19)  Frequently  drinking  an  abundance  of  ice-water  and  cold 
beverages  when  overheated  or  during  meals. 

(20)  Swallowing  infected  sputum  in  dental  and  nasopharyngeal 
su-ppuration. 

Dietary  indiscretions  of  various  kinds  often  lead  to  a  catarrhal 
state  in  the  stomach,  intestine,  or  both.  Frequent  overloading  of 
the  former  is  a  factor,  because  it  distends  the  stomach,  traumatizes 
the  mucosa,  and  sooner  or  later  leads  to  impairment  of  the  motor  and 
secretory  functions  of  the  organ,  with  the  result  that  the  food  is  in- 
sufificiently  salivated,  broken  up,  and  digested,  and,  in  addition,  the 
gastric  juice  abnormally  mixed  is  discharged  into  the  intestine  almost 
continuously,  so  that  the  digestive  apparatus  has  but  little  if  any  time 
to  recuperate  between  meals.     Again,  when  heavy  and  indigestible 


178  ENTERITIS.    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

food  accumulates  in  excessive  amounts,  it  favors  intestinal  catarrh 
and  loose  movements  through  the  abnormal  stimulus  which  it  gives 
to  peristalsis  and  the  secretory  glands.  Undue  intestinal  activity 
and  congestion  of  the  mucosa  may  also  be  incited  by  ice-cold  drinks, 
eating  very  hot  food,  and  the  consumption  of  fruit,  sausages,  certain 
fish,  and  other  articles  of  diet  difficult  to  digest.  Foods,  when  taken 
in  large  amounts  and  those  which  are  improperly  balanced,  lead  to 
undue  fermentation,  putrefaction,  and  the  formation  of  lactic,  butyric, 
acidic,  succinic,  and  other  acids  and  gases  which  pave  the  way  for  the 
catarrhal  state.  Raw,  unhealthy,  and  improperly  cooked  vegetables, 
fruits,  and  meats  are  frequently  difficult  to  digest,  and  are,  therefore, 
conducive  to  bowel  disturbances,  particularly  in  infants  and  children. 
Some  individuals  have  an  idiosyncrasy  to  certain  articles  of  diet, 
which,  when  consumed  even  in  very  small  amounts,  excite  a  catarrhal 
discharge,  viz.:  milk  may  produce  a  diarrhea  in  one  individual  and 
constipation  in  another.  Food  infection  and  ptomain-poisoning,  as, 
for  instance,  the  eating  of  meat  from  diseased  animals  or  that  which 
has  been  exposed  and  infected  beforehand,  or  other  foods  which  con- 
tain pathogenic  bacteria,  their  poisons  or  elemental  toxins,  like  canned 
goods,  fish,  and  shell-fish,  impure  or  spoiled  grain  food  stuffs,  dis- 
eased potatoes,  mushrooms,  etc.,  often  induce  catarrhal  colitis. 

Intestinal  inflammation  is  frequently  secondary'  to  gastrogenic  de- 
rangements where  there  is  snbacidity,  achylia  gastrica,  hyperacidity, 
atony,  motor  insufficiency,  or  malignancy,  which,  according  to  the 
methods  elsewhere  described  (see  Gastrogenic  Diarrhea,  Chapter  X), 
lead  to  stagnation  within  the  stomach,  poor  or  no  digestion,  and  the 
emptying  into  the  gut  of  an  abnormal  juice  and  incompletely  broken 
up  and  digested  food  masses  that  are  beyond  the  ability  of  the  intes- 
tine to  handle.  Such  a  condition  interferes  with  the  functionating 
powers  of  the  liver  and  pancreas,  owing  to  the  abnormal  stimuli 
which  is  brought  about. 

Hepatogenic  and  pancreatogenic  disturbances  resulting  from  reflex 
irritation  and  organic  disease  have  also  been  known  to  aggravate  or 
cause  intestinal  catarrh  where  the  biliar\-  and  pancreatic  secretions 
are  augmented  or  reduced  sufficiently  to  impair  the  intestinal  juice. 

Enterogenic  dyspepsia  (see  Enterogenic  Diarrhea,  Chapter  XI)  is 
also  a  common  cause  of  catarrhal  enteritis,  colitis,  and  enterocolitis. 
This  type  of  catarrh  is  primary  when  (a)  it  is  due  to  a  diminished  secre- 
tion of  the  biliar\%  pancreatic,  or  true  intestinal  secretions;  (b)  they 
are  prevented  from  being  discharged  into  the  duodenum  owing  to 
obstruction  within  the  ducts;  (c)  there  are  pathogenic  changes  in  the 
mucosa  which  would  interfere  with  or  prevent  intestinal  digestion 
and  assimilation;  and  (d)  there  are  imperfect  mastication  and  indis- 
cretions in  diet,  where  more  food  is  consumed  than  the  intestinal 
juices  can  take  care  of,  it  is  indigestible  (such  as  cabbage,  sour- 
crout,  cucumbers,  and  fresh  fruit)  after  passing  through  the  stomach, 
it  is  still  mechanicalh-  irritative,  or  where  the  food  readily  undergoes 
fermentation  and  putrefaction;   and  secondary  when  it  is  consequent 


ETIOLOGY    OF    ENTERITIS,    COLITIS,    AND    ENTEROCOLITIS  1 79 

Upon  gastrogenic  abnormalities,  such  as  subacidity,  achylia  gastrica, 
hyperacidity,  atony,  motor  insufficiency,  or  cancer. 

The  chemicals  and  mediciyies  named  in  the  above  hst,  which  gain 
entrance  to  the  bowel  accidentally  or  by  administration,  when  very 
strong  sometimes  ha\e  a  cauterizing  effect  or  set  up  an  active  inflam- 
mation which  terminates  in  acute  or  chronic  catarrh,  but  remedies 
like  mercury,  arsenic,  silver,  and  the  enumerated  drastic  purgatives 
often  lead  to  a  subacute  catarrhal  inflammation  either  through  re- 
peated irritation  of  the  mucosa,  incident  to  their  passage  through  the 
bowel,  their  effect  upon  the  general  or  local  nervous  apparatus,  tend- 
ency to  augment  ])eristalsis,  or  increase  the  exudation  of  fluids  into 
the  bowel  or  stinuilate  the  intestinal  glands  to  secrete  an  oversupply 
of  mucus. 

Chemical  irritants  and  toxins  which  reach  the  bowel  through  the 
circulation  produce  catarrhal  inflammation  of  the  mucous  mem- 
brane solely  through  their  irritating  propensity,  while  mechanical 
irritants,  such  as  gall-stones,  enteroliths,  foreign  bodies,  act  in  a  similar 
manner,  except  that,  in  addition,  they  traumatize  the  mucosa  and  may 
cause  ulceration  and  suppuration  when  they  become  lodged  or  encysted. 

Acute  and  chronic  intestinal  obstruction,  however  produced,  in- 
variably induce  a  local  catarrhal  inflammation  or  enterocolitis  when 
the  block  is  high,  because  scybala?  accumulate  and  traumatize  the  gut, 
the  pathogenic  and  pyogenic  accidental  and  obligate  intestinal  micro- 
organisms greatly  multiply  and  generate  poisons  oft'ensive  to  the 
bowel,  and  gases  which  form  in  an  enormous  amount  as  a  result 
of  putrefaction  and  irritation  to  the  mesenteric  nerves  stretch  and 
irritate  the  intestine  along  with  retained  mucus  and  fluid  feces,  and 
because  the  discharge  from  ulcers  above  the  obstruction  intensely 
irritate  the  mucosa  and  cause  congestion,  and  later,  when  emptied 
into  the  bowel  below  the  block,  are  so  offensive  that  they  produce 
a  catarrhal  inflammation  which  may  be  complicated  by  well-marked 
erosions,  ulcers,  or  both. 

Children's  diseases,  such  as  measles,  whooping-cough,  scarlet  fever, 
pneumonia,  diphtheria,  digestive  disturbances,  etc.,  not  infrequently 
accompany  or  induce  intestinal  catarrh,  owing  to  the  changes  in  the 
mucosa.  Under  these  circumstances  sepsis  may  complicate  them,  or 
the  effect  of  toxins  may  be  manifest  in  the  circulating  media. 

It  is  natural  that  a  catarrhal  inflammation  of  the  intestine  should 
be  a  forerunner  of  syphililic,  tubercular,  gonorrheal,  and  the  difterent 
types  of  dysenteric  colitis  because  of  its  tendency  to  lower  the  patient's 
vitality  and  leave  the  mucous  membrane  uncovered,  so  that  the 
specific  agents  of  these  infections  ma\-  readily  find  suitable  lodgment 
and  a  gateway  to  the  circulation. 

It  is  also  easy  to  understand  why  catarrhal  enteritis,  colitis,  or 
enterocolitis  should  be  a  sequel  to  such  infectious  diseases  of  the 
bowel,  because  the  mucous  membrane  is  repeatedly  insulted  for  such 
a  long  time  by  the  specific  organisms,  lesions  of  the  accompanying 
mixed  infection,  generated  toxins,  and  oflensive  discharge.     In  not 


l80  ENTERITIS.    COLITIS,    ENTEROCOLITIS.    DIARRHEA    IN 

a  few  instances  considerable  ingenuity  and  patience  are  required  to 
cure  the  intestinal  catarrh  after  the  original  infection  has  completely 
disappeared,  and  in  some  cases,  where  there  is  a  resultant  stricture, 
this  must  be  treated  or  extirpated  before  the  patient  can  obtain  per- 
manent relief. 

Constipation  and  coprostasis  are  nearly  always  complicated  by 
colonic  catarrh,  and  frequently  by  stercoral  diarrhea,  owing  to  the 
irritation  produced  by  retained  offensive  feces,  toxins,  gas  and  dis- 
charges, and  bruising  of  the  mucosa  by  scybalae  and  the  formation  of 
ulcers  through  the  pressure  of  impacted  masses  which  accumulate  at 
the  bowel  flexures.  Once  lesions  have  formed,  peristalsis  is  augmented 
through  action  of  the  intestinal  content  upon  the  terminal  ner\e  fila- 
ments, and  when  the  fecal  collection  assumes  proportions  sulificient 
to  almost  block  the  gut,  a  tendency  to  strain  is  constant,  and  evacua- 
tions are  frequent  and  fluid  because  solid  excreta  cannot  get  by. 

Neurotic  diarrheas  have  been  fully  discussed  elsewhere  (see  Neuro- 
genic Diarrheas,  Chapter  XII),  and  it  is  not  necessan,-  to  do  more 
here  than  mention  the  fact  that  when  disturbing  neuroses  continue 
for  a  long  time  they  interfere  with  digestion,  the  formation  of  normal 
gastro-intestinal  juices,  and  cause  undigested  food  to  be  rushed  through 
the  alimentar\"  tract,  which  irritates  the  mucosa  and  sooner  or  later 
leads  to  catarrhal  enterocolitis. 

Unquestionably,  disturbance  of  the  splanchnic  circulation  is 
conducive  to  enterocolitis,  for  stasis  of  the  portal  vessels  caused  by 
obstructive  liver  and  heart  affections  induces  congestion  of  the 
abdominal  circulation,  and  engorgement  of  these  vessels,  however 
else  produced,  favors  a  hyperemic  state  of  the  mucosa.  The  conclu- 
sions of  Tiirck.  who  attempted  to  demonstrate  this  experimentally, 
are  as  follows,  viz.: 

"Strong  chemic  irritation  produces  congestion  of  all  the  splanch- 
nic or  abdominal  vessels. 

"The  vasomotor  disturbance  thus  produced  results  in  motor  dis- 
turbances of  the  stomach  and  intestines. 

"Prolonged  distention  of  the  stomach  or  intestines  with  air  or 
gas  results  in  splanchnic  congestion,  followed  by  collapse. 

"Toxins  formed  in  the  stomach  may  produce  splanchnic  conges- 
tion as  a  local  reflex  irritation,  or  by  absorption." 

On  a  few  occasions  the  author  has  treated  patients  afflicted  with 
localized  enteritis,  colitis,  sigmoiditis,  or  proctitis  which  were  secondary 
to  inflammaton,-  suppurative  or  malignant  disease  in  other  organs, 
viz..  the  prostate,  bladder,  pehis,  upper  abdomen,  stomach,  appendix, 
or  other  structure.  Numerous  cases  of  catarrhal  and  other  forms 
of  colitis  have  been  recorded  where  the  disease  could  be  traced  to  an 
unhealthy  appendix  which  were  cured  by  appendicostomy  or  appen- 
dectomy. 

From  what  has  been  said,  it  may  be  inferred  that  in  the  vast 
majority  of  instances  catarrhal  enteritis,  colitis,  or  enterocolitis  is 
due  to  pathogenic  micro-organisms,  toxins  of  whatever  kind,  foreign 


ACUTE  CATARRHAL  ENTERITIS  l8l 

bodies,  intestinal  distortion,  or,  in  fact,  anything  which  irritates  the 
mucosa  continuousK-  or  repcatcdh'  at  shorter  or  Ioniser  intervals. 

Pathology  of  Enteritis,  Colitis,  and  Enterocolitis. — The  changes 
which  take  place  in  the  bowel  in  catarrh  of  the  intestine  vary  greatly 
in  different  cases,  dependent  upon  whether  the  disease  is  primary 
or  secondary  to  another  local  or  constitutional  disease,  the  nature  of 
the  cause  or  etiologic  factors  which  produce  it,  and  the  stage  of  the 
inflammatory  process  when  seen. 

The  appearance  of  the  mucous  membrane  in  the  presence  of 
catarrhal  enteritis,  colitis,  or  enterocolitis  is  about  the  same  as  that 
observed  in  the  gastric  and  mucous  membranes  elsewhere  when  simi- 
larly affected.  A  review  of  the  above-named  etiologic  factors  in  the 
disease  explains  why  patients  may  suffer  from  catarrh  of  the  entire 
gastro-intestinal  tract  or  any  one  of  its  several  segments,  \iz.,  '^astro- 
enteritis,  enteritis,  enterocolitis,  appendicitis,  typhlitis,  colitis,  sigmoidi- 
tis, or  proctitis,  though  certain  portions  of  the  bowel  (duodenum,  ileum, 
colon,  and  rectum)  are  very  much  more  frequently  the  seat  of  ca- 
tarrhal inflammation  than  others.  In  other  words,  this  affection 
may  be  distinctly  cir  cum  scribed  or  extend  through  a  considerable 
length  of  intestine,  according  to  the  virulence  of  the  inflammation, 
extent  of  the  toxins  causing  it,  or  character  and  location  of  the  irrita- 
tion. Catarrhal  inflammation  of  any  or  all  parts  of  the  small  or  large 
intestine  is  ever  changing  when  a  series  of  cases  are  studied,  owing  to 
its  varying  degrees,  since  the  mucosa  may  be  ia)  simply  congested  or 
inflamed;  (b)  eroded;  (c)  ulcerated;  (d)  marked  by  hemorrhagic  infarcts; 
(e)  involved  in  a  phlegmonous  (gangrenous)  process;  or  (/)  covered 
with  a  diphtheric  membrane,  though  the  two  last-named  conditions 
complicate  infectious  more  often  than  catarrhal  enterocolitis. 

The  manifestations  of  the  disease  are  not  always  commensurate 
with  changes  in  the  mucosa  and  deeper  structures  of  the  gut,  for  often 
patients  suffer  greatly  when  the  bowel  appears  normal  or  slightly 
congested,  and,  again,  those  afflicted  with  enterocolitis,  where  the 
intestine  is  intensely  inflamed,  eroded,  or  ulcerated,  may  suffer  but 
slightly  from  the  disease. 

Acute  Catarrhal  Enteritis. — In  this  affection  the  mucous  mem- 
brane is  hyperemic,  sensitix  e,  swollen,  and  often  edematous  over  small 
or  large  circumscribed  areas  or  throughout  a  considerable  length  of 
the  intestine,  and  occasionally  the  inflammatory  process  extends 
to  the  submucosa.  In  some  instances,  according  to  the  degree  of 
inflammation  and  character  of  the  intestinal  contents,  the  color  of  the 
mucosa  varies  from  a  pink  to  a  dark  purple,  or  presents  a  dull,  cloudy, 
grayish  appearance.  The  inflammatory  process  concentrates  at  the 
summit  of  the  valvuUe  conniventes  about  the  lymph-vessels,  villi, 
and  solitary  follicles,  but  seldom  involves  Peyer's  patches,  and  occa- 
sionally punctate  hemorrhagic  areas  are  manifest. 

Under  the  microscope  the  secreting  cells  show  marked  acii\ity, 
and  when  the  inflammation  is  active  leukocytes  collect  about  the 
tubular  glands  and  the  capillaries  in  the  submucosa.     "The  blood- 


1 82  ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

vessels  of  the  mucosa,  and  usually  the  submucosa,  are  more  or  less 
distended  with  blood.  Occasionally  small  extravasations  can  be 
seen,  chiefly  between  the  crypts  of  Lieberkiihn.  The  interstices 
between  these  glands  are  frequently  wider  than  normal  and  contain 
more  or  less  abundant  masses  of  round  cells;  the  latter  appearance 
may  be  considered  characteristic  of  true  inflammatory  catarrh. 
Round  cells  are  also  abundant  in  the  most  superficial  part  of  the 
submucosa,  immediately  under  the  muscularis  mucosa;,  and  in  the 
deeper  layers  of  the  submucosa,  chiefly  around  the  blood-vessels. 
The  swelling  of  the  solitary  follicles — if  they  are  swollen  at  all — and 
of  Peyer's  patches  is  probably  due  to  proliferation  of  the  essential 
cells  of  these  glandular  structures  and  in  part  to  immigration  of 
round  cells.  The  epithelium  of  the  mucosa  in  almost  all  cases  is 
detached,  particularly  in  the  large  intestine.  This  I  regard  as 
merely  a  postmortem  phenomenon,  and  I  have  performed  a  num- 
ber of  control  experiments  in  animals  that  strengthen  this  view" 
(Nothnagel). 

The  lining  of  the  bowel  may  be  dry  and  hot  in  the  beginning  of 
acute  enterocolitis,  but  in  a  short  time  becomes  abundantly  smeared 
with  mucus  or  a  discharge  composed  of  it,  pus,  blood,  bile-pigment, 
epithelial  cells,  mucous  shreds,  liquid  feces,  and  undigested  food 
remnants,  according  to  the  virulence  of  the  inflammation  and  changes 
in  the  gut.  In  aggravated  cases  the  discharge,  which  is  enormous, 
may  be  attributed  to  the  exudation  of  fluid  into  the  intestine,  aug- 
mented gastro-intestinal  juices,  and  to  hypersecretion  of  mucus  or 
goblet-cells. 

The  amount  of  pus  and  blood  contained  in  the  mucoid  evacuations 
bears  a  direct  relation  to  the  number  of  erosions  and  ulcers  present. 
Once  the  epithelium  is  destroyed,  pathogenic  and  pyogenic  bacteria 
of  the  bowel  begin  to  play  a  part,  mixed  infection  ensues,  and  the 
affection  passes  from  a  simple  catarrhal  to  a  suppurative  inflammation 
of  the  mucosa,  which  may,  in  aggravated  cases,  be  followed  by  ex- 
tensive ulceration,  submucous  abscesses  and  fistula,  or  a  diffused 
phlegmonous  inflammation  which  destroys  the  mucous  membrane 
over  large  areas,  and  sometimes  causes  death  from  exhaustion,  tox- 
emia, or  perforation  and  peritonitis. 

Hemorrhages  have  occurred  in  the  different  stages  and  types  of 
intestinal  catarrh,  under  which  circumstances  the  affection  is  ordi- 
narily designated  as  hemorrhagic  enteritis,  colitis,  or  enterocolitis. 
Bleeding  may  be  the  first  manifestation  to  suggest  an  inflammatory 
condition  of  the  bowel  or  appear  at  any  time  during  its  progress. 
Hemorrhagic  areas  may  appear  as  diminutive,  dark,  petechial-like 
spots,  erosions,  or  over  the  whole  or  extensive  sections  of  the  bowel 
where  the  mucosa  is  soft,  spongy,  and  presents  an  appearance  typic  of 
this  complication. 

Hemorrhagic  enterocolitis  resembles  typhoid  fc\(.T  in  its  manifes- 
tations, but,  according  to  "Mummery,"  it  is  due  to  a  primary  infec- 
tion of  the  colon  with  the  Diplococcus  pnenmonice.     The  mortality 


ACUTE  CATARRHAL  EXTERITIS  1 83 

of  this  condition  is  very  much  higher  than  that  for  ordinary  catarrhal 
enterocoHtis,  but  the  process  can  usually  be  arrested  by  through-and- 
through  colonic  irrigation. 

When  from  unknown  causes  mucus  collects  upon  the  inner  sur- 
face of  the  bowel,  and  is  evacuated  en  masse  in  the  form  of  tube-like 
moldings  of  the  intestine,  the  inflammatory  process  is  diagnosed  as 
desquamative  enteritis  or  colitis,  according  to  the  segment  of  bowel 
involved.  This  condition,  which  has  also  been  called  pseudo-enteritis, 
enteritis  crouposa  endemica,  enteritis  diphtheritica,  etc.,  may  in  some 
inexplainable  way  occur  in  the  presence  of  both  catarrhal  and  specific 
inflammations  of  the  bowel  as  well  as  mercurial  poisoning,  nephritis, 
etc.,  both  in  infancy  and  in  adult  life.  When  the  disease  is  accom- 
panied l)y  necrotic  changes  in  the  bowel  it  is  characterized  by  a  sudden 
onset,  high  temperature,  toxemia,  and  dysenteric  symptoms,  which 
frequently  and  cjuickly  leiid  to  death  through  exhaustion.  In  case 
the  exudation  is  superficial,  tenacious  membranes  are  visible,  but  when 
the  deeper  structures  are  involved  the  mucosa  has  a  granular,  rasp- 
berry-like appearance,  dotted  here  and  there  with  exudative  deposits, 
but  where  the  inflammation  extends  entirely  through  the  intestine 
the  bowel  becomes  at  least  six  times  its  normal  thickness.  Usually 
this  variety  of  colitis  is  most  marked  in  the  sigmoid  flexure  and  rec- 
tum. It  is  essential  that  acute  desquamative  or  membranous  enteritis 
or  colitis  be  differentiated  from  the  chronic  form  known  as  myxor- 
rhea  coli  (colica  mucosa,  enteritis  membranacea,  etc.). 

When  the  solitary  follicles  and  agminated  glands  in  catarrhal 
enteritis  or  colitis  become  involved,  the  process  is  designated  as 
follicular  enteritis  or  colitis,  a  condition  more  often  caused  by 
bacterial  invasion  in  persons  having  a  lowered  resistance.  As  a 
rule,  intestinal  catarrh  paves  the  way  for  the  specific  organisms  of 
dysentery  or  bacteria  of  the  intestine,  which  dominate  the  disease 
once  they  participate  in  it.  In  this  form  of  inflammation  the  follicles 
are  swollen,  protrude  beyond  the  mucous  surface,  and  are  manifest 
as  anemic  spots  resting  upon  a  highly  colored  basic  membrane. 
Usually  follicles  within  the  colon  do  not  project  above  the  surface, 
but  early  ulcerate  and  form  depressed  lesions  shortly  following  in- 
fection, though  occasionally  they  have  been  observed  as  pinhead 
like  elevations  before  breaking  down.  Owing  to  swelling  which  en- 
sues in  Peyer's  patches  the  mucosa  possesses  a  somewhat  corrugated 
appearance.  There  is  an  accumulation  of  lymphoid  and  round  cells 
in  the  follicular  parenchyma,  which,  together  with  congestion  of  the 
diminutive  blood-vessels,  account  for  the  distention,  swelling,  and 
necrosis  which  follow.  There  is  also  cellular  infiltration  around  the 
follicles  and  into  the  lymph-\essels.  When  necrosis  occurs,  diminutive 
abscesses  may  form  and  in(li\i(hial  ulcers  coalesce  to  make  larger  raw 
surfaces  covered  with  mucus  containing  some  blood-cells.  Woodward 
holds  that  in  some  instances  infection  first  takes  place,  abscesses  result, 
and  the  diminutive  opening  or  lesion  is  caused  by  the  escaping  dis- 
charge. 


184  ENTERITIS.    COLITIS.    ENTEROCOLITIS.    DIARRHEA    IN 

Albrecht,  in  a  case  of  suppurative  follicular  enteritis,  attributed 
it  to  a  bacillus  designated  by  him  as  Bacterium  pseudotubercidosis 
rodent  urn.  because  of  its  resemblance  to  the  plague  bacillus  found 
among  rats.  The  pathologic  findings  also  resembled  those  found  in 
plague. 

The  pathology  of  chronic  intestinal  catarrh  is,  in  many  respects, 
similar  to  that  of  the  acute  variety,  because  in  many  instances  the 
transitional  stage  from  the  latter  into  the  former  is  imperceptible, 
and  the  mucosa  is  congested,  swollen,  and  covered  with  mucus,  but  its 
coloring  is  paler,  often  being  of  a  gray  or  slate  hue  when  there  is  an 
extravasation  of  pigment  between  the  glands  and  at  the  summit  of 
the  villi. 

The  discharge  contains  considerable  mucus  and  epithelium,  the 
collection  of  round  cells  is  smaller,  and  connective-tissue  proliferation 
is  more  marked.  In  chronic  catarrh  the  intestine  may  undergo  atro- 
phic or.  more  frequently,  hypertrophic  changes.  In  the  hypertrophic 
form  the  glands  are  long,  irregular  in  their  course,  and  tend  toward 
the  formation  of  pouches,  and  sometimes,  where  their  mouths  are 
abnormally  closed,  secretory-  cysts  form  (c>"stic  enteritis).  The 
author  has  known  this  condition  to  progress  until  the  connective- 
tissue  hyperplasia  caused  marked  thickening  and  stenosis  of  the 
bowel,  and  in  a  number  of  cases  treated  the  hypertrophic  changes  led 
to  the  formation  of  multiple  small  and  large  polypi  in  the  colon  (colitis 
polyposa),  which  in  some  instances  could  be  clearly  seen  through  the 
sigmoidoscope.  When  such  growths  were  present  the  evacuations 
were  particularly  offensive,  and  usually  contained  considerable  mucus 
thoroughly  mixed  with  pus  and  a  trace  or  large  amount  of  blood. 
When  the  solitary-  and  agminated  glands  are  involved,  owing  to  the 
shape  of  their  contour  the  condition  has  been  designated  as  enteritis 
nodularis  by  Orth.  In  the  presence  of  atrophic  changes  the  reverse 
attains,  and  the  mucous  membrane  and  other  intestinal  tunics  diminish 
in  thickness,  villi  are  less  prominent  or  absent,  and  the  lymph-nodules 
rupture  or  become  necrotic,  giving  way  to  follicular  ulceration.  In 
chronic  catarrh,  ulceration  may  or  may  not  be  a  complication,  but 
when  present  the  lesions  are  much  more  numerous  and  extensive  in 
the  later  than  earlier  stages  of  the  disease,  particularly  in  ignorantly 
treated  or  neglected  cases.  This  is  due  in  a  large  measure  to  acti^■ity 
of  the  colon  bacillus  and  other  pathogenic  micro-organisms  which 
become  troublesome  as  soon  as  the  mucosa  is  eroded  by  the  irritating 
discharge  or  straining.  Once  the  ulcerative  process  has  become 
extensive  it  is  difficult  to  arrest  with  the  best  treatment,  and  when 
repair  takes  place  the  former  location  of  ulcers  is  indicated  by 
diminutive  whitish  scars  and  puckered  depressions,  which  give  the 
mucosa  an  uneven  indentated  appearance,  or  when  a  number  of  ulcers 
have  persistently  coalesced  to  form  large  encircling,  raw  areas  the 
cicatricial  tissue  from  them  causes  partial  or  complete  stenoses. 

Ulcerative  lesions  may  appear  as  superficial  erosions,  small  ulcers, 
or  occasionally  lesions  of  considerable  size,  but  except  in  the  presence 


ACUTE  CATARRHAL  ENTERITIS  1 85 

of  a  virulent  mixed  infection  the  destruction  of  tissue  is  not  so  exten- 
sive or  deep  as  that  caused  by  the  various  t\'pes  of  infectious  coUtis; 
consequently,  severe  hemorrhage,  submucous  abscesses,  glandular 
involvement,  perforation,  peritonitis,  and  stricture  seldom  complicate 
simple  catarrhal  enteritis,  colitis,  or  enterocolitis. 

Usually,  when  a  patient  suffers  regularly  week  after  week  from 
chronic  diarrhea,  and  has  about  the  same  number  of  evacuations  daily, 
ulcerative  colitis  prevails,  and  the  frequency  of  the  evacuations  is 
proportionate  to  the  number  of  ulcers  in  the  bowel,  and  the  diarrhea 
will  improve  or  get  worse  accordingly  as  the  ulcerative  process  is 
healed  or  permitted  to  extend. 


CHAPTER    XVII 

ENTERITIS,    COLITIS,    ENTEROCOLITIS     NON-SPECIFIC  (?) 
INTESTINAL  CATARRH  ,   DIARRHEA   IN     Continued, 

SYMPTOMS,   DIAGNOSIS 

Symptoms. — The  manifestations  that  accompany  non-specific 
enteritis  and  colitis  are  numerous  and  extremely  variable  in  a  series 
of  cases  dependent  (a)  upon  whether  the  affection  is  acute  or  chronic; 
(b)  virulence  of  the  inflammation;  (c)  cause  of  the  disturbance;  (d) 
disease  complicating  it;  (e)  condition  of  the  patient's  mind  and  ner- 
vous mechanism;  (J)  part  played  by  digestive  disturbances;  (g)  sequelse; 
(h)  location  and  extent  of  the  catarrhal  inflammation;  and  (i)  other 
factors  which  at  one  time  or  another  influence  the  symptomatolog>-. 

While  the  symptoms  of  acute  and  chronic  enterocolitis  are  similar 
in  some,  they  dift'er  materially  in  other  respects,  but  in  both  there  is  a 
variation  in  the  accompanying  manifestations  when  the  inflammatory 
process  is  located  in  different  segments  of  the  small  intestine  and 
colon.  Following  a  discussion  of  the  usual  symptoms  of  enterocolitis 
the  disturbances  which  point  to  catarrh  in  the  several  segments  of  the 
gut  (duodenitis,  ileitis,  colitis,  sigmoiditis,  and  proctitis)  will  be 
pointed  out.  The  author  recognizes  that  intestinal  catarrh  may  arise 
in  and  be  confined  to  any  and  all  parts  of  the  small  and  large  intestine, 
and  he  believes  that  in  a  goodly  percentage  of  cases  the  inflammation 
involves  at  least  a  part  of  both  the  small  gut  and  colon,  and  for  this 
reason  he  considers  it  advisable  to  discuss  the  disturbances  arising 
from  the  affections  under  the  caption  of  enterocolitis.  L'nquestion- 
ably,  colitis  frequently  exists  independently,  but  the  probabilities  are 
that  enteritis  does  not  exist  for  any  great  length  of  time,  because  the 
irritating  discharges  and  poor  digestion  which  accompany  it  must 
necessarily  lead  to  an  inflamed  state  of  the  colonic  mucosa,  owing  to 
the  fact  that  it  is  being  constantly  irritated  by  acrid  discharges  and 
coarse,  undigested  food  remnants. 

Acute  enterocolitis  occasionally  comes  on  slowly,  and  the  patient 
complains  of  anorexia,  feeling  of  malaise,  and  abdominal  discomfort, 
but  generally  there  are  no  prodromata,  and  shortly  following  the  onset 
of  disease  (which  is  sudden)  the  patient  complains  of  severe  sensa- 
tions, of  pressure  and  fulness  in  the  abdomen,  intestinal  soreness 
and  gurgling  (borbor\'gmusj,  boring,  griping  or  colicky  pains  (which 
begin  in  the  mesogastrium  and  radiate  in  all  directions),  diarrhea, 
sometimes  nausea  and  pain,  loss  of  appetite,  and  a  temperature  of 
ioi°  F.  in  mild  and  103°  to  104°  F.  in  severe  cases.  The  character- 
istic manifestations  are  the  slightly  griping  or  the  colicky  pains  and 
diarrhea,  but  the  former  gradualh'  or  immediately  subside  following 
186 


SYMPTOMS  1 87 

the  evacuations,  which  are  frequently  explosive  in  character.  Often 
the  movements  closely  follow  one  upon  the  other,  and  then  the  pa- 
tient has  a  temporary  respite  from  diarrhea  and  pain  until  the  next 
crisis.  This  is  the  case  in  catarrh  of  the  small  gut,  but  not  in  colitis, 
where  the  movements  are  not  always  preceded  i)y  griping,  occur  at 
more  regular  intervals,  and  usually  are  not  of  the  explosive  variety. 
When  the  upper  is  affected  and  the  loiver  intestine  remains  normal, 
the  patient  may  void  considerable  mucus,  but  diarrhea  is  slight  or 
absent,  and  the  dejecta  is  semisolid  or  firm,  because  the  fluid  feces 
are  hurried  through  the  small  gut  into  the  colon  by  abnormal  peris- 
talsis, and  remain  there  long  enough  for  their  watery  constituent  to 
be  partially  or  completely  absorbed.  However,  in  the  average  case 
of  acute  enterocolitis,  diarrhea  is  marked,  and  the  number  of  evacua- 
tions \ary  from  two  or  three  to  fifteen  or  twenty  daily,  and  in  the 
beginning  are  composed  of  feculent  masses,  and  later  of  a  watery  or 
highly  irritating  fluid  (containing  feces,  mucus,  and  serum)  which 
scalds  the  rectum  and  induces  tenesmus. 

Diarrhea  here  is  attributable  to  (a)  peristalsis,  which  rushes  the 
unprepared  chyme  and  feces  through  the  gut  so  quickly  that  the  water 
cannot  be  taken  up;  {b)  impairment  of  the  absorptive  mechanism 
of  the  colon;  (c)  serous  transudation  into  the  bowel;  {d)  increased 
activity  of  the  secretor\^  glands;  ie)  mental  impressions  and  neuroses 
which  influence  the  intestinal  motor  and  secretory  nerves;  (/)  gastro- 
genic,  hepatogenic,  pancreatogenic,  and  enterogenic  disturbances 
which  unbalance  the  gastro-intestinal  juices;  (g)  toxins  which  act  con- 
stitutionally or  upon  the  bowel;  and  (h)  anything  which  caUvSes  irri- 
tation of  the  intestinal  mucosa.  In  these  cases  the  quantity  of  the 
discharge  is  out  of  proportion  to  the  food  ingested,  and  the  first  stools 
have  a  brownish  tint,  but  later  are  of  a  pale-yellow  color  and  foul 
smelling.  Ordinarily,  diarrhea  is  more  persistent,  and  the  number  of 
evacuations  greater  in  colitis  than  enteritis.  The  odor  of  the  dejecta 
may  be  normal,  absent,  or  very  offensive,  and  the  reaction  is  acid  or 
usually  alkaline,  according  to  the  food  consumed. 

In  some  instances  the  fluid  movements  are  preceded  or  accompanied 
by  collections  or  evacuations  of  scybake,  the  expulsion  of  which  is 
followed  by  marked  relief. 

Macroscopic  and  microscopic  examination  of  the  dejecta  in  a  series 
of  cases  will  show  that  they  are  composed  of  fecal  matter,  mucus,  pus, 
Ijlood,  epithelium,  leukocytes,  calcium  phosphates,  oxalates,  fat, 
undigested  food  remnants  (muscle-fibers,  albuminous  particles,  casein, 
undigested  fat,  particles  of  starch,  etc.),  and  living  or  dead  micro-or- 
ganisms, separately  or  together,  according  to  the  diet,  cause  of  the 
inflammation,  or  changes  taking  place  in  the  bowel. 

Duodenal  tubes  and  buckets  are  also  useful  diagnostic  adju^■ants 
in  this  class  of  cases. 

Although  constipation  and  diarrhea  are  usually  considered  as  op- 
posite manifestations,  both  are  frequently  symptoms  of  enterocolitis, 
and  more  particularly  catarrh  of  the  large  intestine.     Sometimes  one 


l88  ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

and  sometimes  the  other  dominates  the  condition,  but  more  often 
there  are  alternating  loose  movements  and  costiveness,  or  diarrhea 
may  supervene  for  several  days  or  weeks  and  then  give  way  to  consti- 
pation. In  this  class  of  cases  constipation  or  obstipation  may  ensue 
when  the  intestine  becomes  blocked  by  an  enterolith  or  foreign  body, 
and  when  the  bowel  contains  an  irritant  of  any  kind  which  induces 
hypertonus  of  the  muscular  tunic  and  causes  enterospasm  (spastic 
constipation)  which  partially  or  completely  blocks  the  gut.  The 
modus  operandi  by  means  of  which  frequent  fluid  stools  are  incited 
has  already  been  given. 

Catarrhal  constipation  is  frequently  a  troublesome  symptom  in 
the  presence  of  ileocecal  catarrh,  which  renders  the  valve  irritable 
and  causes  it  to  contract  at  irregular  intervals  or  remain  closed  for 
shorter  or  longer  periods,  and  in  membranous  enteritis  characterized 
by  dried  shreds  or  sheets  of  mucus  or  tubular  casts  of  the  bowel,  which 
obstruct  the  intestine  or  cause  its  musculature  to  contract  and  excite 
spastic  constipation  until  this  membrane  has  been  expelled. 

Enterospasm  may  involve  the  small  intestine  and  induce  delayed 
evacuations,  but  most  frequently  occurs  in  the  colon,  being  induced 
occasionally  by  indigestible  food  remnants,  such  as  cucumbers,  peas, 
sweet  potatoes,  etc.,  which  irritate  the  gut  and  give  rise  to  tetanus, 
and  bearing-down,  labor-like  pains. 

Fever  may  not  appear,  be  slight,  or,  in  exceptional  cases,  where  the 
inflammation  is  virulent,  the  temperature  may  rise  several  degrees, 
but  fever  is  more  regularly  present,  higher,  and  persistent  in  infectious 
than  in  catarrhal  enterocolitis.  When  nausea  and  vomiting  are  annoy- 
ing there  is  usually  some  complicating  gastrogenic  disturbance; 
steatorrhea  indicates  that  the  pancreatic  secretion  is  deficient  or  absent, 
and,  when  biliary  secretion  is  marked,  Gmelin's  reaction  for  unchanged 
bile-pigment  is  positive.  As  has  been  previously  indicated,  pai?i  may 
be  manifest  as  a  discomfort,  or  be  of  the  boring,  colicky  variety,  ac- 
companied by  an  intense  desire  to  evacuate  the  bowel,  and  there  is 
also  intestinal  tenderness  upon  pressure. 

The  amount  and  character  of  the  mucus  in  the  stools  is  dependent 
upon  the  extent  and  virulence  of  the  inflammation  and  nature  of  the 
irritant  causing  it,  but  the  quantity  of  accompanying  pus  and  blood 
is  slight  when  erosions  and  ulcers  are  few,  and  considerable  when 
they  are  large  and  numerous.  Dark,  clotted  blood  points  to  lesions 
in  the  small  intestine  or  upper  colon;  bright  fresh  blood  indicates 
bleeding  from  the  rectum  (though  both  are  rare). 

In  hemorrhagic  colitis  bleeding  is  unimportant  when  it  comes  from 
petechial  spots,  but  is  dangerous  when  the  mucosa  is  spong>'  and 
raw  over  extensive  areas. 

When  acute  enteritis  or  enterocolitis  is  of  short  duration  or  mod- 
erately severe  it  does  not  impair  the  general  health,  but  when  the 
inflammation  is  virulent  or  long  drawn  out,  metabolism  is  disturbed, 
malnutrition  takes  place,  the  patient  becomes  exhausted,  melancholy, 
anemic,  languid,  indilTerent  to  social  and  business  duties,  has  no  ap- 


CHRONIC    CATARRHAL    IvNTERITIS,    COLITIS,    AND    ENTEROCOLITIS       189 

petite,  complains  of  headache,  loses  weipjht,  and  suffers  from   a   poor 
circulalion  and  inu-ciilar  weakness. 

Chronic  Catarrhal  Enteritis,  Colitis,  and  EnterocoUtis.  —Chronic 
intestinal  catarrh  may  be  primary  and  a  continuation  of  the  acute 
form,  or  secondary  to  the  infectious  bowel  diseases,  constitutional 
or  organic  afTections  (valvular  lesions,  kidney  disease,  hepatic  cir- 
rhosis, cancer,  stricture,  etc.),  or  one  of  the  many  etiologic  factors 
in  catarrh  of  the  bowel;  consequently,  the  manifestations  of  the  dis- 
ease vary  greatly  in  different  cases.  As  a  rule,  however,  diarrhea  is 
the  dominating  symptom,  and  frequently  it  is  the  only  one  to  suggest 
the  nature  of  the  trouble.  By  the  time  catarrhal  inflammation  has 
become  chronic  it  is  usually  centered  in  the  colon,  the  mucosa  of  which 
has  become  irritable,  inflamed,  and  occasionalh'  eroded,  or  ulcerated 
lesions  (from  mixed  infection,  etc.),  which  tend  to  augment  the  fre- 
quency and  fluidity  of  the  movements,  because  they  stimulate  mucous 
glands  to  oversecrete  and  expose  terminal  ner\'e  filaments  to  the 
irritants  within  the  bowel,  which  excite  stimuli  that  bring  about  fre- 
quent strong  and  prolonged  peristaltic  contractions  and  lead  to  ex- 
pulsion of  the  feces  and  discharge.  Those  interested  in  a  further 
study  of  the  symptoms  of  diarrhea  and  the  changes  which  take  place 
in  the  stools  under  van^-ing  conditions  in  chronic  intestinal  catarrh, 
are  referred  to  Nothnagel,^  who  has  given  a  clear  description  of  them. 

When  the  inflammation  is  active  at  a  given  point,  or  some  irritant 
or  foreign  body  becomes  lodged  and  excites  simultaneous  contrac- 
tion of  the  circular  and  longitudinal  muscular  fibers,  they  cause  spastic 
constipation  fenterospasm),  which  may  continue  for  several  hours  or 
days,  or  may  alternate  with  diarrhea.  While  the  destruction  of 
tissue  is  ver>'  much  less  marked  in  chronic  catarrhal  than  in  infec- 
tious enterocolitis,  it  may  take  place,  and,  owing  to  the  erosions  and 
ulcers,  intestinal  auto-intoxication,  with  its  train  of  symptoms,  bleed- 
ing, and  suppurative  follicular  colitis,  may  be  present,  and  submucous 
abscesses  and  fistulas  have  been  known  to  form  in  neglected  cases. 

Intestinal  tenderness  is  characteristic,  and  abdominal  pain  and 
cramps  may  occur,  but  less  frequently  and  in  a  milder  form  than 
in  acute  enterocolitis,  and  it  is  notable  that  suft'ering  is  greatest  several 
hours  after  meals,  particularh-  when  the  patient  has  been  indiscreet 
in  diet.  Under  such  circumstances,  in  addition  to  pain  there  are  sen- 
sations of  abdominal  distention  (bloating)  and  an  imperative  desire 
for  an  evacuation,  which  comes  shortly  and  relieves  the  patient. 
When  gases  collect  in  enormous  quantities  the  patient  becomes  uneasy 
and  suff^ers  from  borborygmi,  colicky  pains,  shortness  of  breath, 
palpitation,  cerebral  congestion,  vertigo,  or  angina  pectoris,  which 
prevail  until  the  gas  is  belched  up  or  escapes  through  the  anus. 

When  catarrhal  inflammation  is  concentrated  in  the  sigmoid 
flexure  or  rectum  (particularly)  a  constant  desire  for  an  evacuation, 
intense  straining  during  the  same,  and  burning  and  dull  aching  pain 
in  the  lower  bowel  after  stool  dominate  other  symptoms. 

1  Diseases  of  the  Intestines  and  Peritoneum,  American  ed.,  1907,  p.  193. 


iqo  enteritis,  colitis,  enterocolitis,  diarrhea  in 

Chronic  catarrh  is  a  persistent  affection,  and  requires  months 
or  years  to  cure;  though  when  properly  treated  the  variety  and  in- 
tensity of  the  manifestations  are  subject  to  marked  changes.  Vic- 
tims of  it  sometimes  complain  bitterly  of  diarrhea  and  mucous  dis- 
charges for  a  time,  and  then  for  a  short  or  long  interval  these  symp- 
toms are  quiescent,  during  which  time  the  patient  leads  a  comfort- 
able existence  and  is  able  to  attend  to  his  duties.  The  state  of  the 
bowel  and  depleted  condition  of  the  subject  makes  him  an  easy 
victim  to  infectious  diseases  of  the  intestine  and  some  organic  and 
constitutional  ailments.  Among  the  more  common  complications 
are  appendicitis,  rheumatism,  reflex  phenomena,  intestinal  lithiasis, 
dyspepsia,  indicanuria.  and  pneumonia.  When  catarrhal  entero- 
colitis persists  for  a  very  long  time  and  is  cured,  the  functional  dis- 
turbances dependent  upon  it  cease,  but  the  bowel  never  becomes  per- 
fectly normal  because  the  mucous  membrane  remains  thickened, 
spong\-,  dotted  over  with  excrescences  or  scars,  and  the  glands  are 
hypersensitive  or  atrophied,  and  the  gut  may  be  strictured.  hyper- 
trophied  or  contracted,  and  tube-like. 

The  objective  symptoms  most  frequently  present  in  cases  of  entero- 
colitis are  the  diarrhea  and  constantly  changing  character  of  the 
stools,  gas  distention,  tenderness  on  palpation,  pot-belly  when  enter- 
optosis  is  a  factor,  and  now  and  then  splashing  sounds  after  eating  or 
drinking  when  the  abdomen  is  tapped  suddenly  one  or  more  times. 

Diagnosis. — In  suspected  cases  of  enteritis  or  colitis  it  is  ad- 
visable to  ascertain  if  the  condition  started  as  such  or  followed  some 
other  disease — tubercular,  syphilitic,  helminthic,  entamebic.  or  bacil- 
lary  colitis;  enterogenic,  gastrogenic.  hepatogenic,  or  pancreatogenic 
dyspnea;  circulatory-  obstruction,  neuroses,  etc. — thoroughly  examine 
and  analyze  the  gastric  juice  and  feces,  for  by  so  doing  many  doubt- 
ful points  can  be  cleared  up. 

By  studying  the  patholog>'  and  analyzing  the  symptomatolog\' 
outlined  above  indicative  of  catarrhal  inflammation,  it  is  compara- 
tively easy  to  diagnose  simple  enteritis,  colitis,  or  enterocolitis,  and  to 
determine  whether  or  not  the  affection  is  acute  or  chronic. 

It  is  much  more  difficult,  however,  to  define  the  limitations  of  the 
disease  and  to  isolate  the  part  or  segment  of  the  small  or  large  intes- 
tine when  the  catarrhal  inflammation  does  not  extensively  involve  the 
upper  or  lower  bowel,  or  both,  and  yet  this  is  essential  if  the  patient 
is  to  be  rationally  treated.  Owing  to  the  diagnostic  importance  of 
determining  the  exact  location  of  the  disease  when  it  is  circumscribed, 
the  author  will  first  outline  the  best  methods  of  doing  this,  and  will 
then  call  attention  to  some  essential  features  useful  in  making  a  dif- 
ferential diagnosis  between  intestinal  catarrh  and  other  affections  the 
manifestations  of  which  often  simulate  those  of  enteritis  and  colitis. 

Localization  of  Intestinal  Catarrh  (Enteritis,  Colitis,  Entero- 
colitis, Duodenitis,  Jejunitis,  Ileitis,  Cecitis,  Sigmoiditis,  and  Proc- 
titis).— When  there  is  a  gastro-enteritis  or  colitis  the  diagnosis  is 
fairlv  easv  when  the  stomach  and  intestinal  contents  are  examined 


LOCALIZATION    OF    INTESTINAL    CATARRH  I9I 

following  test-meals  by  a  summarization  of  their  chief  maiiifesta- 
tions.  In  case  the  catarrh  is  of  ^astrogenic  origin,  and  particularly 
when  it  results  from  achylia  gastrica,  periodic  diarrhea  ensues.  Gas- 
trogenic  dyspepsia  most  freciuently  excites  catarrh  in  the  upper  small 
intestine,  and  undigested  food  remnants  appear  in  the  dejecta  shortly 
thereafter. 

The  localization  of  intestinal  catarrh  is  often  very  difficult  because 
the  symptoms  induced  by  intlammation  of  the  entire  and  individual 
sections  of  the  gut  are  mainly  the  same,  and  because  disturbances 
from  the  disease  located  in  the  same  portion  of  the  gut  in  different 
cases  vary  in  accordance  with  the  exciting  cause,  virulence  of  the 
inflammation,  and  the  part,  if  any,  played  by  comp)licating  ailments. 
At  times,  when  the  history  has  been  taken  into  consideration,  the 
patient  studied  for  a  sufficient  length  of  time,  the  stomach  and 
bowel  contents  repeatedly  inspected  and  analyzed,  macroscopically, 
microscopically,  before  and  following  the  administration  of  test-meals, 
and  the  sufferer  subjected  to  a  thorough  physical  examination,  one 
can  determine  if  a  particular  part  or  several  segments  of  the  intestine 
are  involved  in  the  catarrhal  process. 

Since  the  therapeutics  of  catarrhal  duodenitis,  jejunitis,  ileitis, 
ileocecitis,  typhlitis,  colitis,  sigmoiditis,  and  proctitis  vary,  the  author 
will  briefly  call  attention  to  their  peculiarities,  that  they  may  be  in- 
di\iduall\-  diagnosed,  after  he  has  mentioned  the  essential  points  of 
differentiation  between  enteritis  and  colitis. 

Catarrh  of  the  small  intestine  occurs  very  much  less  frequently 
than  catarrhal  colitis,  and  in  the  former  the  inflammation  in  most 
cases,  sooner  or  later,  extends  to  the  lower  bowel,  but  non-specific 
colonic  catarrh  seldom  passes  upward  to  the  ileum  or  higher. 

Enteritis  {Catarrh  of  the  Small  Intestine). — One  of  the  chief  char- 
acteristics of  enteritis  is  the  rumbling  heard  and  felt  by  palpation  in 
the  intestinal  coils  of  the  right  iliac  fossa.  There  is  increased  fermen- 
tation and  a  multiplication  of  the  bacteria,  and  likewise  an  augmen- 
tation of  the  gases  (carbonic,  hydrogen  sulphid,  etc.)  which  stimulate 
peristalsis. 

Catarrh  of  the  small  intestine  does  not  necessarily  influence  either 
the  stools  or  act  of  defecation,  and  in  a  series  of  cases  the  evacuations 
may  be  normal,  slightly  increased,  or  delayed,  particularly  when  the 
inflammation  is  confined  to  the  upper  segment.  Owing,  however,  to 
the  participation  of  gastrogenic  or  local  disturbances,  dyspepsia, 
abdominal  distention,  soreness  on  pressure,  belching  of  gases,  and 
boring  pains  in  the  umbilical  region  are  frequent  manifestations. 
When  the  inflammatory  process  extensively  involves  the  mucosa  of 
the  small  gut,  diarrhea  is  the  dominating  symptom,  because  peris- 
talsis is  abnormally  stimulated,  the  secretory  function  of  the  bowel 
is  enhanced,  and  chyme  improperly  prepared  in  the  jejunum  passes 
into,  irritates,  and  produces  undue  activity  of  the  colon.  I'nder  such 
circumstances  the  evacuations  frequently  have  an  acid  reaction,  the 
odor  of  volatile  acids,  are  light  brown,  yellowish  or  greenish  in  color 


192  ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

(in  presence  of  hydrobilirubin),  foamy,  mixed  with  gas,  contain  un- 
changed bile-pigment,  muscle-fibers,  fat  globules,  epithelia,  etc.,  and 
when  there  is  a  chronic  catarrh  of  the  small  gut,  Rosenheim's  test- 
diet  will  demonstrate  the  presence  of  well-preserved  starch  bodies 
without  sheaths  (which  easily  give  the  iodin  reaction)  or  remnants 
of  fat  (flakes,  crystals,  drops).  According  to  Rosenheim,  these  find- 
ings of  disturbed  assimilation  point  to  enteritis  only  when  they  are 
demonstrable  in  formed  stools,  for  neurogenic  and  other  severe  diar- 
rheas may  be  associated  with  them.  Mucus  is  often  absent  from  the 
dejecta  in  catarrh  of  the  upper  small  intestine,  but  is  more  frequently 
present  when  the  inflammatory  process  involves  the  ileum. 

Tenderness  upon  pressure  in  the  region  of  the  mesogastrium  and 
colicky  pains  are  more  aggravated  in  enteritis  than  in  colitis. 

Circumscribed  pain  and  tenderness  in  the  region  of  the  appendix, 
cecum,  and  rectum  point  to  catarrh  in  these  localities,  but  under  other 
circumstances  are  unreliable  as  diagnostic  signs  of  localized  catarrh, 
because  they  are  so  disseminated  that  the  patient  cannot  locate 
them,  but  pain  at  and  centered  about  the  umbilicus  and  tenderness 
upon  pressure  point  to  enteritis,  and  when  the  same  manifestations 
are  obtained  in  the  right  and  left  iliac  regions  the  patient  probably 
suffers  from  enterocolitis. 

Nothnagel  maintains  that  yellow  mucous  granules  in  the  stools  are 
characteristic  of  catarrh  in  the  small  bowel  or  upper  colon,  but  this 
is  denied  by  Boas  and  A.  Schmidt. 

Urinary  examination  is  not  a  reliable  diagnostic  aid  in  cases  of 
intestinal  catarrh,  though  now  and  then  albuminuria  and  cylindruria 
(Fischl)  are  complications,  hyaline  casts  have  appeared  in  the  urine, 
and  indican  and  the  ethylsulphuric  acids  so  common  in  many  bowel 
ailments  are  frequently  demonstrable  in  this  condition.  Where  the 
stools  give  an  acid  reaction  it  indicates  a  catarrhal  state  of  the  small 
intestine. 

Duodenitis. — Catarrh  limited  to  the  duodenum  is  characterized 
by  icterus  incident  to  swelling  or  blocking  of  the  ductus  choledochus, 
but  in  the  absence  of  this  manifestation  a  diagnosis  of  duodenitis 
must  be  made  with  reservation.  In  the  presence  of  icterus,  if  lo- 
calized pain  and  tenderness  on  pressure  above  the  umbilicus,  gas- 
tric disturbances,  constipation  alone  or  alternating  with  diarrhea, 
and  extensive  cutaneous  burns  are  manifest,  one  is  justified  in  con- 
cluding that  he  has  a  catarrhal  duodenitis  to  deal  with.  This  con- 
dition has  been,  but  need  not  be,  mistaken  for  typhlitis  and  appendi- 
citis, because  the  pain  consequent  upon  the  latter  is  right  sided. 
Microscopic  and  macroscopic  mucus  in  the  dejecta  also  point  to  this 
affection,  as  do  undigested  food  remnants  under  the  above  circum- 
stances. 

Jejunitis  and  Ileitis. — A  catarrhal  inflammation  of  the  jejunum  is 
imp(jssible,  and  catarrh  of  the  ileum  is  extremely  difiicult  to  diagnose 
except  by  postmortem  examination.  Since  there  is  no  means  of  difter- 
entiating  between  catarrhal  inflammation  in  these  segments  of  the 


COLITIS  193 

gut,  and  ileitis  is  more  frequent  and  troublesome,  only  the  differen- 
tiating points  (jf  the  latter  will  be  discussed.  In  the  jejunum  or  in 
catarrh  of  the  ileum  (particularly  the  upper  part)  bile-pigment  is 
frequently  present  and  changes  the  mucus  to  an  orange  or  greenish- 
yellow  hue,  and  also  discolors  the  epithelium,  round  cells,  and  fat. 
The  stools  have  an  acid  reaction  and  contain  more  or  less  mucus 
mixed  with  feces.  The  amount  and  character  of  the  former  and 
whether  or  not  the  stools  are  softened,  fluid,  and  frequent  depends 
upon  the  extent  of  the  catarrhal  process  and  the  degree  of  peristalsis 
and  glandular  activity  caused  by  it.  When  a  major  portion  or  the 
entire  ileum  and  jejunum  are  affected,  borbor\gmi,  colicky  pains, 
intestinal  distention,  gurgling,  occasional  bloating,  and  soreness  or 
tenderness  on  pressure  over  the  central  portion  of  the  abdomen  are 
troublesome  manifestations.  Chief  reliance,  however,  should  be 
placed  upon  a  careful  macroscopic  and  microscopic  examination  of  the 
dejecta  before  and  following  test-meals.  Frequently  the  feces  re- 
main firm  or  semisolid  when  the  inflammation  is  confined  to  the 
ileum;  most  often,  however,  there  is  an  enterocolitis,  the  dominant 
symptom  of  w^hich  is  daily  or  periodic  diarrhea.  Diminutive  and 
larger  undigested  food  remnants,  such  as  starch,  fat.  and  muscle- 
fibers,  point  to  entcrogenic  dyspepsia  and  ileitis,  as  does  undecomposed 
bile-pigment,  demonstrable  by  Gmelin's  test.  Xothnagel  lays  great 
stress  upon  the  bile-stained  stools  and  ver\-  small,  pigmented  balls  of 
mucus  in  this  condition  (ileitis).  Here,  as  in  catarrhal  inflammation 
in  other  parts  of  the  bowel,  indicanuria  is  marked. 

Colitis. — When  attempting  a  diagnosis  of  catarrhal  colitis  it  is 
well  to  bear  in  mind  that  the  inflammatory  process  may  be  confined 
exclusively  to  the  large  bowel,  in  which  case  there  are  present  well- 
defined  manifestations  and  signs  in  the  dejecta  which  greatly  help 
one  to  identify  it,  or  there  may  be  an  enterocolitis  and  accompanying 
manifestations  that  are  confusing.  In  catarrhal  colitis,  pure  and 
simple,  gastrogenic  disturbances  are  rarely  present  and  undigested 
food  remnants  seldom  appear  in  the  stools.  Slight,  moderate,  or  ex- 
hausting  diarrhea  is  the  pathognomonic  symptom  of  catarrhal  colitis, 
and  always  prevails  except  when  spastic  constipation  (enterospasm) 
is  brought  on  by  ulcers,  inflamed  areas,  or  collections  of  dried  mucus 
which  excite  the  simultaneous  contraction  of  the  circular  and  longi- 
tudinal muscular  layers  of  the  bowel.  This  form  of  obstipation  may- 
alternate  with  diarrhea  or  dominate  it  for  a  period  of  several  hours, 
days,  or  weeks,  and  is  encountered  more  often  in  membranous  than  in 
catarrhal  colitis.  While  these  patients  complain  of  soreness  and 
tenderness  on  pressure,  the  discomfort  is  felt  o\er  the  course  of  the 
colon  and  is  not  concentrated  at  the  midabdominal  region  as  in  enteri- 
tis, and,  though  they  suffer  severely  from  colic,  the  pains  are  less 
frequent  and  intense  than  those  which  complicate  catarrhal  inflam- 
mation of  the  upper  small  intestine  and  enterocolitis.  Borborygmi 
and  gurgling  on  palpation,  common  to  enteritis  of  the  duodenum, 
jejunum,  and  ileum,  are  rarely  encountered  when  the  inflammation  is 
13 


194  ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

confined  to  the  colon.  Patients  afflicted  with  colitis  often  maintain 
a  fairly  good  appetite  and  digestion  in  contradistinction  to  enteritis, 
but  they  are  often  in  a  run-down  condition  because  of  the  exhaustion 
consequent  upon  frequent  and  fluid  movements  and  complicating 
mixed  infection.  Sufferers  from  colitis  are  often  despondent  and 
nervous  on  account  of  the  persistent  diarrhea,  but  depression  and 
nervous  phenomena  are  more  frequent  and  exaggerated  in  enteroco- 
litis, because  here,  in  addition  to  suffering  from  auto-intoxication, 
the  patient  worries  because  he  knows  if  he  eats  it  will  aggravate  his 
condition.  Naturally,  when  the  catarrhal  process  is  diffused,  and 
when  the  mucosa  is  eroded  or  ulcerated,  the  accompanying  manifes- 
tations are  augmented:  the  diarrhea,  because  of  increased  exudation, 
peristalsis,  and  secretion;  soreness  and  pain,  owing  to  the  lesions; 
muscular  spasms,  from  exposure  of  terminal  nerve  filaments  to  irri- 
tation, and  the  stools  more  watery;  the  absorption  of  fluids  in  the 
colon  has  been  diminished  or  arrested.  When  the  disease  is  influenced 
by  neuroses  or  psychic  impulses  the  daily  evacuations  are  increased, 
are  sanguineous  in  character,  and  are  voided  in  the  early  morning 
(in  rapid  succession),  and  later  in  the  day  when  the  bowel  is  inflamed 
or  ulcerated. 

Mucus,  in  small  or  large  amounts,  may  be  seen,  macroscopically, 
in  the  dejecta,  in  the  form  of  jelly,  threads,  whitish  balls,  membran- 
ous casts,  or  as  a  glistening  covering  for  scybalae  or  lumpy  feces,  when 
the  catarrhal  process  involves  the  transverse  and  descending  colons, 
sigmoid  flexure,  and  rectum.  The  quantity  of  mucus  secreted  in  the 
upper  colon  and  small  intestine  under  the  same  conditions  is  consider- 
ably less,  and  usually  cannot  be  seen  with  the  naked  eye,  but  appears 
as  threads  or  brown  or  greenish  grains  under  the  microscope.  Again, 
mucus  intimately  mixes  with  feces  in  upper  intestinal  catarrh,  and 
appears  free  in  the  presence  of  sigmoiditis  or  proctitis.  Pus,  blood, 
burning  pain,  and  tenesmus  increase  in  amount  or  degree  in  propor- 
tion as  the  inflammatory  process  approaches  the  anus. 

Percussion  usually  brings  forth  a  distinctly  tympanitic  note,  and 
by  palpation  the  colon  is  often  recognizable  owing  to  its  hyperplas- 
tic condition,  distended  state,  or  its  knot-like  feel  when  there  is  en- 
terospasm.  Deep  palpation  also  elicits  tenderness  over  the  entire 
colon  or  an  individual  segment  when  the  catarrh  is  circumscribed. 
When  the  transverse  colon  is  filled  with  gas  it  raises  upward  and  les- 
sens hepatic  dulness,  and  complete  colonic  distention  interferes  with 
respiration,  disturbs  the  heart,  and  may  cause  angulation  or  twisting 
of  the  gut,  localized  pain,  and  obstruction  at  points  where  it  is  bound 
down. 

Catarrhal  colitis  is  not  accompanied  by  a  material  rise  in  tempera- 
ture except  when  there  is  mixed  infection,  under  which  circumstances 
the  temperature  may  be  irregular,  and  vary  from  ioo°  to  ioi°  F.  or 
rise  to  103°  or  104°  F.,  when  submucous  or  deeper  abscesses  form. 

In  concluding  the  discussion  regarding  the  points  of  diff^erentia- 
tion  between  enteritis  and  colitis  it  may  be  as  well  to  mention  that  the 


SIGMOIDITIS  195 

latter  runs  a  more  regular  course  than  the  former,  wliich  is  inclined 
to  periodicit}-,  so  that  the  patient  is  fairly  comfcjrlabie  and  able  to  be 
about  for  a  time,  and  then  is  confined  to  his  bed,  owing  to  the  intense 
suffering  which   prevails  during  the  exacerbations  or  crisis. 

When  there  is  enterocolitis,  diarrhea  is  a  more  marked  symptom 
than  in  catarrhal  enteritis  or  colitis,  and  the  majority  of  evacuations 
occur  in  the  earl\-  morning,  owing  to  fecal  fermentation  which  takes 
place  during  the  night. 

Anders  diflerentiates  between  enteric  catarrh  and  colic  as  follows: 

ENTERIC    CATARRH.  COLIC. 

Diarrhea  is  generalh'  present.  Constipation  is  present. 

Fever  may  be  slight  or  marked.  No  fever. 

Pain  is  griping  and  followed  by  diarrheal  Pain  is  colicky,  more  severe,  and  is  not 

stools.  followed  by  diarrheal  discharges. 

Tenderness  in  the  interval  between  pains.  Xo  sensitiveness  on  palpation. 

Ileocecal  valve  catarrh  (catarrh  of  Bauhin's  valve)  has  been  dis- 
cussed as  an  entit\'  by  some,  but  it  is  doubtful  if  it  can  be  identified, 
for  it  is  frequenth-  associated  with  catarrhal  inflammation  of  the 
ascending  colon,  the  cecum,  or  ileum. 

The  ileocecal  valve  is  a  favorite  site  for  intestinal  disease,  particu- 
larl\-  the  infectious  types  (amebiasis,  tuberculosis,  typhoid  fever,  ac- 
tinomycosis, etc.).  The  feces  in  ileocecal  vah'e  catarrh  are  fluid  and 
putrescent,  mucus  is  present  in  the  form  of  threads,  and  undigested 
food  remnants  do  not  appear.  Patients  thus  afflicted  complain  of 
localized  discomfort  or  pain  and  bloating,  on  account  of  which  the 
aftection  has  been  mistaken  for  enteritis.  Occasionally  the  e\"acua- 
tions  are  irregular  in  character  and  either  constipation  or  diarrhea  may 
prevail.  Cecal  gurgling  is  also  indicative  of  catarrh  at  and  about 
Baifliin's  valve. 

Typhlitis  is  accompanied  b>'  manifestations  similar  to  those  just 
mentioned,  but  constipation  is  a  more  frequent  complication,  and 
cecal  gas  distention  is  more  marked  and  pressure  over  the  head  of  the 
colon  elicits  decided  tenderness  or  pain  and  slight  gurgling. 

Appendicitis  (catarrhal)  is  accompanied  by  sharp,  characteristic 
pain  located  at  AIcBurney's  point,  tenderness  over  the  cecal  region  on 
pressure,  rigidity  of  the  abdominal  muscles,  and  frequently  constijm- 
tion,  though  in  exceptional  cases  slight  or  severe  diarrhea  may  pre- 
vail. 

As  the  inflammation  becomes  more  marked,  mucus  collects  within 
the  appenflix,  the  patient's  suffering  is  intensified,  the  local  circu- 
lation is  impaired,  and  soon  perforation  or  gangrene  ensues,  condi- 
tions which  lead  to  peritonitis,  a  rise  in  the  temperature,  and  symptoms 
of  collapse.  In  the  chronic  form  the  patient  may  recover  from  a 
severe  attack  and  remain  in  comparatively  good  h(\alth  for  weeks, 
months,  years,  or  until  another  crisis  sets  in. 

Sigmoiditis  induces  the  manifestations  common  to  catarrh  in 
other  segments   of    the  colon,   but  is  distinguishable  by  the  fulness 


196  ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

apparent  in  the  left  iliac  fossae,  increased  thickness  of  the  gut,  localized 
pain  and  soreness,  and  augmented  evacuations. 

Proctitis. — Catarrhal  inflammation  of  the  rectum  is  typified  by 
persistent  diarrhea,  incessant  desire  to  empty  the  bowel,  unrelieved 
feeling  following  the  movements,  occasional  colicky  pains  in  the 
sigmoid  region,  burning  in  the  rectum,  and  numerous  small  evacua- 
tions, accompanied  and  followed  by  straining. 

Small  round,  mucus-covered  scybala  are  discharged  from  time  to 
time,  but  usually  mucus  is  not  admixed  with  the  feces,  as  in  enteritis 
or  colitis,  but  is  evacuated  free  and  in  large  amounts  in  the  form  of 
strings,  casts,  jelly-like  masses,  or  a  thin,  glairy  discharge.  When 
constipation  prevails,  mucus  may  be  evacuated,  pure,  ahead  of  the 
movement,  or  as  a  coating  for  the  lowermost  hardened  end  of  the 
fecal  mass.  When  the  rectal  mucosa  is  extensively  inflamed,  eroded, 
or  ulcerated  the  levator  ani  and  sphincter  muscles  spasmodically 
contract  and  greatly  enhance  the  patient's  suffering,  under  which 
circumstances  either  or  both  muscles  clasp  the  finger  like  a  strong 
rubber  band  when  it  is  introduced  into  the  rectum. 

In  these  cases,  when  the  inflammatory  process  is  acute,  the  mucosa 
feels  hot,  swollen,  and  slippery.  There  is  no  difficulty  in  diagnosing 
acute  and  chronic  sigmoiditis  and  proctitis,  because  the  bowel  can  be 
accurately  inspected  through  the  sigmoidoscope  or  proctoscope. 

A  painstaking  abdominal  examination  is  essential  in  cases  of  en- 
teritis and  colitis,  because  in  this  way  one  can  gain  much  information 
regarding  the  localization  of  painful  and  tender  spots  upon  pressure, 
tumors,  obstruction,  the  degree  and  location  of  gas  accumulations, 
peristaltic  waves,  enterospasm,  impacted  fecal  masses,  splashing  and 
gurgling  sounds,  and  sometimes  the  limitation  of  the  catarrhal  inflam- 
mation or  other  abnormal  condition  which  might  cause,  simulate,  or 
complicate  enterocolitis. 

Mistaken  diagnoses  are  common  when  this  or  infectious  bowel 
diseases  are  located  in  the  upper  colon,  cecum,  or  segments  of  the 
small  intestine,  but  no  one  except  the  ignorant  or  careless  should 
confuse  enterocolitis,  colonic  infections,  obstructive,  or  other  lesions 
with  each  other  when  they  are  situated  in  the  sigmoid  flexure  or  rec- 
tum, because  their  nature,  appearance,  and  exact  location  can  be 
accurately  determined  by  proctosigmoidoscopic  inspection  and  digital 
examination  of  the  lower  bowel. 

A  close  analytic,  macroscopic,  and  microscopic  study  of  the  urine 
is  useful,  but  not  always  positively  indicative  of  enterocolitis,  though 
in  characteristic  cases  it  is  hypertoxic  and  contains  skatol,  indol,  indi- 
can,  occasionally  a  slight  amount  of  albumin,  and  the  proportions  of 
solids  may  vary  when  the  temperature  is  high  or  the  patient  is 
excessively  run  down. 

Blood  examination  is  necessary,  and  will  gi\e  some  idea  as  to 
whether  or  not  the  patient  is  anemic,  suftering  from  a  mixed  infection, 
auto-intoxication,  or  peritoneal  involvement.  After  all,  the  chief 
diagnostic  reliance  in  catarrh  of  the  small  intestine,  colon,  or  individual 


DIFFERENTIAL    DIAGNOSIS  197 

segments  of  the  gut  Is  based  upon  repeated  examinations  of  the 
stomach  and  bowel  contents  independently  of  and  following  Schmidt's 
or  other  test-meals,  for  in  this  way  only  can  one  form  any  idea  as  to 
whether  the  ingredients  of  the  gastric  juice  and  succus  entcricus  are 
properh'  balanced,  if  the  feces  contain  entameba,  bacilli,  helminths,  or 
other  infective  agents,  foreign  bodies,  pus,  blood,  mucus,  threads  of 
tissue  or  undigested  food  remnants,  the  finding  of  which  greatly  aid  in 
clearing  up  the  diagnosis.  The  author  will  not  further  discuss  the 
macroscopic  and  microscopic  findings  in  the  feces  here  because  this 
has  been  done  in  the  symptomatology  and  more  fully  in  Cliapter  II 
devoted  to  The  Diagnosis  of  Diarrhea. 

In  this  and  simulative  affections  of  the  bowel  Kuttner  lays  con- 
siderable stress  upon  the  color  of  the  dejecta  and  summarizes  his 
conclusions  as  follows,  \iz.: 

Ocher-colored  stools: 

In  adults  these  stools  suggest  disturbances  in  the  small  bowel. 

Green  stools: 

In  adults  these  stools  suggest  jejunal  diarrhea. 

In  infants  they  are  due  to  increase  of  alkali  in  the  upper  parts  of  the  intestine,  or 
to  an  oxydizing  femient. 

Fermenting  stools: 

These  stools  are  usually  light  brown,  foamy,  and  have  an  acid  or  cheesy  odor. 
They  generally  indicate  the  milder  intestinal  disturbances. 

Putrefying  stools: 

These  stools  are  dark  colored  and  indicate  serious  trouble,  such  as  dysenter>'  or 
carcinoma  of  the  large  intestine. 

Differential  Diagnosis  of  Catarrhal  Enteritis,  Colitis,  and  Entero- 
colitis.— Catarrh  of  the  small  and  large  intestine  has  been  frequently 
confused  with  affections  of  the  bowel  which  induce  irregular  or  fluid 
movements  and  ailments  of  other  organs  which  cause  diarrhea.  The 
following  are  the  diseases  most  often  mistaken  for  intestinal  catarrh, 
viz.:  Ptomain-poisoning,  typhoid  fever,  appendicitis,  peritonitis,  colic, 
infectious  diseases  of  the  small  intestine  and  colon,  tuberculosis,  enta- 
mebiasis.  bacillary  dysentery,  helminthiasis,  lues,  gonorrhea,  amyloid 
degeneration,  neurogenic  diarrhea,  membranous  enterocolitis,  intes- 
tinal ulcers  from  burns,  diseases  of  the  pancreas  and  li\er,  gastrogenic 
and  enterogenic  dyspepsia,  chronic  coprostasis  and  cancer,  benign 
tumors,  stricture,  and  other  forms  of  bowel  obstruction. 

Ptomain-poisoning  can  be  differentiated  from  enteritis  and  colitis 
by  the  extreme  suddenness  of  the  attack,  severity-  of  the  symptoms 
(vomiting,  pallor,  diarrhea,  tendency  toward  collapse,  and  uncon- 
sciousness), taking  a  history,  ascertaining  if  the  patient  has  consumed 
unhealthy  shell-fish,  spoiled  or  infected  meat,  ice-cream,  canned  goods, 
or  mushrooms,  etc.,  and  by  examining  suspected  food  and  the  feces 
for  bacilli  and  toxins  that  might  cause  the  trouble. 

Typhoid  fever  is  distinguishable   by  the  rose-rash,  dicrotic  pulse, 


198  ENTERITIS.    COLITIS.    ENTEROCOLITIS.    DIARRHEA    IN 

high  and   characteristic    temperature-curNc.   stupor,  enlarged  spleen 
or  liver,  and  Widal  test. 

Appendicitis  comes  on  suddenly,  is  characterized  by  intense  pain 
in  the  right  iliac  region,  rigidity  of  the  adbominal  muscles,  tenderness 
and  pain  upon  pressure  over  the  cecal  region,  constipation,  etc. 

Peritonitis  quickly  leads  to  general  abdominal  distention,  pain 
and  tenderness  upon  pressure,  constipation,  marked  rise  in  tempera- 
ture, fast  and  thread-like  pulse,  facial  expression  indicative  of  suffer- 
ing and  anxiety,  tympany,  and  muscular  rigidity. 

Colic  is  usually  traceable  to  gall-bladder  or  duct  disturbances,  or 
more  frequently  to  the  eating  of  indigestible  food  or  backing  up  of 
gases  proximal  to  a  fecal  impaction. 

Infectious  diseases  of  the  intestine,  such  as  tubercular,  syphilitic, 
gonorrheal,  entamebic.  helminthic,  balantidic.  bacillan.-  and  coccidic 
colitis,  etc.,  are  confined  chiefly  to  the  colon,  and  can  be  accurately 
diagnosed  by  means  of  fecal  and  blood  examinations,  which  reveal  the 
specific  etiologic  agent — tubercle,  Shiga.  Flexner,  Strong.  Hiss,  or 
other  bacilli,  round-,  tape-,  or  hook-worms  or  their  eggs,  coccidia,  go- 
nococci.  spirochetes,  or  other  microscopic  organism — responsible  for  the 
infection.  Infectious  enteritis  or  colitis  is  further  distinguishable  by 
obstinate  diarrhea,  sallow  complexion,  serious  digestive  disturbances, 
tenesmus,  and  the  frequent  abundant  discharge  of  pus.  blood,  or 
mucus,  and  their  lack  of  response  to  the  usual  dietan,-  and  medicinal 
treatment.  When  tuberculosis  is  suspected,  examination  of  the  lungs 
is  imperative,  because  this  type  of  enteritis  or  colitis  is  nearly  always 
secondary-  and  the  infection  is  caused  by  bacilli  which  have  been 
coughed  up  and  swallowed.  Patients  afflicted  with  intestinal  infec- 
tions are  more  weakened  in  mind  and  body  than  those  afllicted  with 
simple  or  catarrhal  enterocolitis,  and  frequently  suffer  from  abscesses 
in  local  or  distant  parts  owing  to  extensive  ulceration  and  the  mixed 
infection  which  ensues  once  continuity  of  the  mucosa  is  broken. 

Amyloid  degeneration  (in  the  later  stages)  is  sometimes  accompanied 
by  manifestations  similar  to  those  of  an  intestinal  catarrh,  but  it 
affects  the  patient  more  generally,  and  the  histor\-  will  indicate  that 
other  viscera  were  involved  prior  to  the  appearance  of  troublesome 
intestinal  symptoms. 

Neurogenic  diarrhea  is  mistaken  for  this  condition  more  often  than 
the  above  affections,  but  its  differentiation  is  not  difficult  because  it 
occurs  in  ner\-ous  individuals  easily  influenced  by  psychic  impulses, 
the  stools  are  sanguineous,  take  place  in  the  early  morning,  occur  in 
rapid  succession,  contain  no  blood  or  mucus,  are  passed  without  pain 
or  tenesmus,  and  the  diarrhea  can  be  improved  or  controlled  by  psycho- 
therapy and  physical  therapeutic  measures  better  than  by  medication, 
dieting,  and  enteroclysis. 

Membranous  colitis  has  been  mistaken  for  catarrhal  enteritis  or 
colitis,  although  there  is  little  reason  for  it,  because  spastic  constipation 
is  always  a  prominent  symptom,  diarrhea  is  seldom  if  ever  a  complica- 
tion, and  when  it  occurs  in  extremely  nervous  individuals  or  persons 


DIFFKRENTIAL    DIAGNOSIS  1 99 

suffering  from  angulation,  twisting,  adhesions,  or  blocking  of  the  gut, 
and,  further,  because  the  mucosa  is  less  often  congested  and  mucus 
visibly  appears  in  the  stools  periodically  in  the  form  of  long  strips, 
twisted  strings,  large  jelly-like  masses,  or  casts  of  the  bowel. 

Enteritis  consequent  upon  cutaneous  burns  can  be  diagnosed  by 
ol)taining  a  history  of  the  injury. 

MaU'^nant  and  benign  groivths  which  obstruct  the  intestine  and  lead 
to  specihc  or  stercoral  intiammation  and  ulceration  frequently  cause 
diarrhea,  gas  distention,  digestive  disturbances,  and  mucus,  pus,  and 
blood  in  the  dejecta;  but  their  diagnosis  is  not  difificult  when  high  up, 
and  is  easy  when  the  tumor  is  located  in  the  sigmoid  flexure  or  rec- 
tum, and  can  be  inspected  through  the  sigmoidoscope  or  felt  with  the 
finger.  In  the  presence  of  malignancy  the  patient  is  cachectic,  rapidly 
loses  weight,  and  the  evacuations  are  frequent  and  offensive. 

Tumors  and  intestinal  adhesions,  angulation,  twisting,  invagination, 
and  foreign  bodies  of  the  colon  can  usually  be  diagnosed  by  locating 
tender  and  painful  spots,  noting  the  distended  gut  above  and  empty  gut 
below  the  block,  palpating  for  swellings  and  ascertaining  if  diarrhea, 
which  may  alternate  with  constipation,  was  preceded  by  difficulty  in 
securing  daily  evacuations.  Frequent  stools,  accompanied  by  marked 
straining  and  no  relief  to  the  patient,  are  indicative  of  obstructive 
lesions  situated  in  the  sigmoid  flexure  or  rectum  or  at  the  anus. 

Pancreatic  bowel  disturbances  are  rare,  and  can  usually  be  differ- 
entiated from  catarrhal  enterocolitis  by  fecal  examination,  which 
shows  an  abnormal  amount  of  fat  in  the  dejecta. 

Gastrogenic  and  enterogenic  dyspepsia  may  simulate  enterocolitis, 
cause  or  be  associated  with  it,  and  often  a  correct  diagnosis  cannot 
be  arrived  at  until  the  stomach  and  intestinal  contents  have  been 
repeatedly  analyzed  and  studied  macroscopically,  microscopically, 
and  chemically  to  determine  if  there  is  subacidity  or  achylia  gastrica, 
hyperacidity,  atony  or  motor  insufficiency,  or  abnormality  in  the 
ratio  of  the  ingredients  composing  the  succus  entericus. 

Finally,  when  attempting  a  differential  diagnosis  of  catarrhal 
enteritis,  colitis,  or  enterocolitis  it  is  well  to  exclude  organic  diseases 
of  the  lungs,  heart,  and  liver  because  in  some  instances,  owing  to  the 
venous  obstruction  which  accompanies  them,  the  blood-serum  exudes 
into  the  bowel  and  increases  the  fluidity  of  the  feces  and  number  of 
dailv  evacuations. 


CHAPTER   XVIII 

ENTERITIS,    COLITIS,    ENTEROCOLITIS    (NON-SPECIFIC  (?) 
INTESTINAL  CATARRH),   DIARRHEA  IN  {Concluded) 

TREATMENT,   PROGNOSIS 

The  treatment  of  inflammatory  conditions  involving  the  small  and 
large  intestine,  as  well  as  their  individual  segments,  requires  consid- 
erable ingenuity  and  patience  to  obtain  a  satisfactory  result.  Re- 
cently, because  of  our  better  understanding  of  the  etiology  of  this  and 
allied  affections,  considerable  progress  has  been  made  in  the  treatment 
of  enteritis  and  colitis,  but  much  remains  to  be  done  before  the  treat- 
ment can  be  relied  upon  to  control  or  arrest  catarrhal  enterocolitis  in 
a  reasonable  time  without  leaving  sequelae. 

It  is  conceded  that  acute  catarrh  of  the  small  intestine,  colon,  or 
both  can,  in  the  majority  of  instances,  be  quickly  and  satisfactorily 
relieved;  chronic  enteritis  and  colitis  cannot,  because  in  this  class  of 
cases  the  inflammation  has  existed  for  a  long  time  and  organic  changes 
have  taken  place  in  the  mucosa  and,  perhaps,  other  of  the  intestinal 
tunics  to  such  an  extent  that  it  is  difficult  or  impossible  to  overcome 
them,  even  though  the  progress  of  the  catarrhal  inflammation  has 
been  checked.  Owing  to  this  abnormal  state  the  intestine  remains 
irritable  after  the  troublesome  manifestations  of  enterocolitis  have 
been  relieved,  and  the  patient  may  be  subjected  to  relapse  in 
case  he  becomes  indiscrete  as  to  his  diet,  consumes  alcoholic 
stimulants,  becomes  overactive,  or  subjects  himself  to  exposure  dur- 
ing inclement  weather.  To  this  extent  the  prognosis  of  chronic 
enteritis  and  colitis  is  bad,  but  it  should  be  remembered  that  catarrhal 
symptoms  are  controllable  and  the  disease  is  curable  in  many  instances, 
and  in  others  it  can  be  regulated  so  that  the  patient  remains  com- 
fortable and  can  be  self-supporting  if  he  will  follow  instructions. 

Cases  of  acute  and  chronic  enteritis  and  colitis  require  individual 
consideration  from  a  therapeutic  standpoint,  because  the  diet  and 
remedial  measures  suitable  for  one  are  unfit  for  another  on  account 
of  the  varied  etiology  of  the  disease.  The  author  will  follow  the 
usual  custom  of  separately  discussing  the  therapeutics  of  acute  and 
chronic  catarrhal  inflammation  of  the  intestine,  because  the  methods 
of  handling  them  differ  and  the  treatment  of  the  former  is  simple  in 
comparison  with  the  latter. 

Acute  Enteritis,  Colitis,  and  Enterocolitis. — Medical  treatment  is 
not  required  in  the  handling  of  acute  catarrhal  inflammation  of  the 
bowel  in  many  instances,  because  the  attack  is  of  short  duration  and 
subsides  spontaneously,  or  the  patient  can  be  relieved  by  having  him 


ACUTE    ENTERITIS,    COLITIS,    AND    ENTEROCOLITIS  20I 

rest  in  bed  and  restrict  his  diet  to  fluid  and  non-irritating  nourish- 
ment, and  by  alleviating  his  discomfort  and  pain  through  the  ayipli- 
cation  of  turpentine  stupes  to  the  abdomen. 

Before  instituting  the  treatment  in  this  class  of  cases  it  must  first 
be  ascertained  whether  or  not  the  gut  is  infected,  the  liver  or  pancreas 
are  abnormal,  the  bowel  manifestations  are  modified  by  malaria  or 
general  affections,  and  if  there  is  gastrogenic  or  entcrogenic  dyspepsia 
or  other  ailment  which  would  cause  or  augment  intestinal  catarrh. 
When  such  complications  arise  they  must  either  be  corrected  before 
or  receive  due  consideration  while  the  enteritis  and  colitis  are  being 
cared  for. 

In  cases  of  enterocolitis,  pure  and  simple  prophylactic  measures, 
such  as  removing  irritating  toxins,  fecal  impactions,  foreign  bodies 
from  the  bowel,  protecting  the  patient  against  exposure,  rest  in  bed, 
and  control  of  the  diet,  are  indicated. 

Rest  in  bed  is  of  the  greatest  importance  during  acute  crises,  par- 
ticularh'  when  the  temperature  is  high  or  diarrhea  and  cramps  are 
distressing,  but  when  these  manifestations  subside  the  patient  may 
be  permitted  to  be  up  and  around  during  his  convalescence. 

Control  of  the  diet  must  not  be  overlooked  in  acute  enteritis  and 
colitis,  since  indiscretions  as  regards  the  amount  and  character  of  the 
food  eaten  invariably  aggravate  the  catarrhal  inflammation.  The 
preliminary  diet  should  be  sparing,  simple,  and  non-irritating,  and 
composed  mainly  of  hot  black  peppermint  or  camomile  tea,  cognac, 
cocoa,  strained  gruels,  and  nourishing  soups.  Later,  as  the  soreness, 
pain,  and  diarrhea  become  less  annoying,  koumiss,  zoolak,  the  Metch- 
nikoff  sour  milk,  barley,  rice,  cereals,  bread  and  butter,  scraped  meats, 
soft-boiled  eggs,  and  baked  or  mashed  potatoes  may  be  permitted,  and 
after  a  few  days,  if  the  patient  continues  to  improve,  pigeon,  chicken, 
and  afterward  veal  and  other  meats  may  be  eaten.  During  the 
attacks,  meat,  raw  fruit,  green  vegetables,  alcohol,  cold  drinks  and 
ice-cream,  cucumbers,  fat,  acids,  and  sweets  are  contra-indicated,  and 
the  patient  should  be  cautioned  against  fasts  and  overeating. 

Dietary  indiscretions  frecjuently  cause  a  relapse,  and  for  this  reason 
it  is  advisable  for  the  patient  to  guard  his  diet  for  a  few  days,  weeks, 
or  until  he  has  completely  recovered. 

The  medical  treatment  of  enterocolitis  is  largely  symptomatic, 
and  consists  chiefly  in  prescribing  remedies  which  will  (a)  free  the 
bowel  of  toxins,  scybala',  and  other  irritating  substances;  {b)  relieve 
enterospasm  and  pain,  and  (c)  diminish  the  frequency  and  fluidit\'  of 
the  stools. 

In  the  preliminary  treatment  calomel  should  be  administered  in 
divided  doses,  and  in  an  amount  varying  from  3  to  lo  gr.  (0.2-0.6) 
because  of  its  cathartic  and  antiseptic  effect,  but  in  the  absence  of 
biliousness,  castor  oil,  5j  to  ij  (30-60),  may  be  substituted  for  it. 
Where  purging  of  the  bowel  is  desirable,  Epsom  or  Glauber's  salts, 
5j  to  ij  (30-60),  or  a  saline  mineral  water  (Carabana,  Hunyadi, 
Apenta,  etc.)  should  be  prescribed  as  often  as  indicated. 


202  ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

In  the  average  case  belladonna  is  preferable  to  opium  and  other 
drugs  for  the  relief  of  discomfort  and  pain,  because  in  enterocolitis 
they  arise  mainly  from  cramps  and  the  soreness  consequent  upon 
them,  a  condition  for  which  the  tincture  of  belladonna,  nji  lo  (0.60), 
or  atropin,  j^-^  gr.  (0.0006),  are  ideal,  because  they  produce  complete 
relaxation  of  the  gastro-intestinal  musculature  when  administered 
three  or  four  times  daily.  The  benefit  derived  from  these  agents  can 
be  greatly  enhanced  by  keeping  the  patient  quiet  in  bed,  applying 
hot  abdominal  stupes,  and  administering  hot  colonic  saline  enemata, 
adjuncts  which  should  be  discontinued  as  soon  as  relief  is  obtained. 
In  the  presence  of  intense  pain  or  persistent  diarrhea,  when  belladonna 
fails  to  meet  the  indications,  tincture  of  opium,  mi  10  (o.6o-),  or  codein, 
gr.  I  to  I  (0.02-0.03),  every  three  hours,  will  bring  prompt  relief  and 
enable  the  patient  to  sleep.  Opiates  are  invariably  contra-indicated 
in  the  beginning,  because  they  arrest  peristalsis  and  frequently  pre- 
vent the  expulsion  of  toxins  or  other  substances  which  are  irritating 
the  intestinal  mucosa. 

In  extremely  aggravated  cases,  where  the  bowel  is  highly  inflamed 
or  eroded,  and  pain  and  diarrhea  are  troublesome,  temporary  relief 
may  be  secured  through  the  agency  of  salol,  guaiacol,  bismuth,  tannal- 
bin,  chalk,  beta-naphthol,  or  other  antiseptic,  soothing,  and  astrin- 
gent remedies  in  5-  or  lo-gr.  doses  (0.30-0.60),  three  or  four  times 
daily,  alone  or  in  combination  with  belladonna  or  opium. 

Enemata  or  enteroclysis  are  often  beneficial,  but  occasionally 
they  induce  considerable  pain  and  are  promptly  expelled.  The 
irrigants  which  have  proved  most  useful  in  the  author's  practice  are 
normal  saline  and  ichthyol,  protargol,  argyrol,  and  permanganate 
solutions  (1:2000),  administered  through  a  return-flow  tube  or  a 
fountain-syringe  when  they  are  to  be  retained.  The  number  and 
amount  of  the  irrigations  require  to  be  varied  in  accordance  with  the 
extent  and  severity  of  the  inflammation.  Often  slippery  elm  or  oat- 
meal water  and  infusions  of  camomile  or  flaxseed  tea  are  more  sooth- 
ing and  give  better  results  than  the  above  irrigations. 

Treatment  of  Chronic  Enterocolitis  (Enteritis,  Colitis). — The  ther- 
apeutics required  here  depend  upon  the  chronicity  of  the  disease, 
dominant  symptoms,  infection,  and  the  part  played  by  other  ailments. 
First  of  all,  the  hygienic  condition  of  the  sufferer  should  be  improved 
as  much  as  possible.  Complete  or  temporary  rest  in  bed  is  advisable, 
since  it  secures  inactivity  of  the  mind  and  body ;  and  this  class  of 
patients  should  avoid  violent  exercise,  particularly  during  the  heat 
of  the  day,  exposure  to  inclement  weather,  irregular  hours,  rapid 
eating  or  overfeeding,  partaking  of  intoxicating  drinks,  attending  to 
business  or  social  duties  which  excite  or  make  them  nervous,  and 
drinking  unboiled  water  that  might  be  infected  with  entamebae, 
dysenteric  bacilli,  or  helminths,  etc. 

Individuals  suffering  from  chronic  enterocolitis  should  guard  their 
diet  closely  and,  so  far  as  practicable,  carry  out  the  dietary  sugges- 
tions made  below. 


DIETETIC    TREATMENT  203 

Dietetic  Treatment.  'I'hc  (iifUir\-  in  this  class  of  cases  requires 
frequent  changing  to  meet  the  indications,  both  in  reference  to  the 
amount  and  articles  of  food  composing  it.  While  it  is  adv'isable  to 
closely  restrict  the  diet  during  times  when  the  intestine  is  extremely 
irritable  and  the  patient  suffers  severely  from  diarrhea  and  pain, 
it  is  not  good  treatment  to  starve  these  patients  or  limit  them  to  a 
particular  variety  of  food  during  the  intervals  between  the  crises, 
because  when  this  is  done  the  loss  in  vitality  will  overcome  the  benefits 
derived  from  other  sources.  Many  individuals  afflicted  with  chronic 
colitis  and  enterocolitis  improve  faster  when  permitted  almost  a 
full  diet,  foods  known  to  disagree  with  them  are  excluded,  and  oils, 
medication,  and  irrigations  are  employed  to  minimize  irritation  and 
heal  lesions  within  the  bowel.  In  no- case  should  a  diet  be  inaugurated 
until  after  the  gastro-intestinal  contents  have  been  repeatedly  exam- 
ined following  Schmidt's  test-meals,  and,  under  all  circumstances,  when 
instituted  it  should  be  made  as  bland  and  non-irritating  as  possible, 
and  contain  a  liberal  amount  of  easily  absorbable  nutriment. 

Permitted  Foods  and  Drinks. — During  severe  attacks  the  diet  should 
be  closely  restricted  as  regards  the  amount  and  character  of  the  foods, 
and  only  those  which  are  not  irritating  and  leave  little  residue,  such  as 
nourishing  soups,  peppermint  and  camomile  tea,  barley-  and  rice- 
water,  cocoa,  and  strained  gruels,  should  be  consumed.  Milk  (steril- 
ized, boiled,  or  with  lime-water)  in  suitable  cases  is  an  ad\isable  ad- 
junct to  the  treatment,  but  it  is  sometimes  objectionable,  because  it 
may  agree  with  one  and  aggravate  the  condition  in  another  patient. 

In  mild  or  subaaife  cases  of  catarrhal  colitis,  in  addition  to  the 
above,  eggs  (soft  boiled  or  scrambled),  gluten  preparations,  gruels, 
rice,  cereals,  arrowroot,  custards,  sweetbreads,  brains,  strained  meat 
soups,  extracts  or  jellies,  scraped  or  lean  roast  beef,  selected  fish, 
milk  if  it  agrees,  chicken,  vegetable  purees,  macaroni,  sago,  fresh  but- 
ter, toasted  and  stale  bread,  koumiss,  matzoon,  zoolak,  sour  milk 
made  from  Bacillus  bulgaricus,  weak  tea,  and  cocoa  may  be  taken  in 
reasonable  amounts. 

In  chronic  colitis,  where  the  patient  suffers  but  slightK-  trom  diar- 
rhea or  cramps  except  during  exacerbations,  a  more  lil)er;il  diet,  in- 
cluding meats  and  most  vegetables,  ma,y  be  permitted. 

Patients  afflicted  with  catarrhal  inflammation  are  better  when  they 
eat  oftener  and  consume  a  smaller  amount  at  each  meal,  and  less 
meat  should  be  allowed  when  the  patient  suffers  from  indicanuria, 
and  fewer  vegetables  when  fermentation  is  active.  Milk  should  be 
prescribed  if  feasible  because  it  is  nourishing,  helps  to  control  the 
intestinal  flora,  when  cooked  with  salicylic  acid  greatly  diminishes 
intestinal  bacteria,  and  the  fat  from  it  is  superior  to  that  obtained 
from  vegetables.  Lactobacillin  and  sour  milk  produced  by  means 
of  the  Bacillus  bulgaricus  are  frequently  but  not  always  useful  in  this 
class  of  cases,  because  they  tend  to  displace  the  colon  bacillus. 
Schmidt  holds  that  the  latter  can  decompose  starch  and  albumin,  and 
recommends  pure  carbohydrates  when  putrefaction  predominates,  and 


2C4  ENTERIOTS.    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

albumin  when  fermentation  is  excessive.  The  value  of  the  sour 
milk  treatment  can  be  augmented  by  employing  sugar  of  milk  with  it. 

A  prolonged  cereal  diet  is  often  objectionable,  since  it  may  cause 
or  aggravate  diarrhea  in  patients  having  hyperchlorhydria. 

Meat- juices,  beef-tea,  and  albumin  preparations  favor  the  forma- 
tion of  albumoses,  and,  according  to  Schmidt,  are  indicated  in  pan- 
creatic insufficiency,  as  evidenced  by  undigested  meat-fibers  in  the 
stool.  When  vegetable  remnants,  cellulose,  etc.,  appear  in  the  de- 
jecta, they  indicate  enterogenic  dyspepsia  with  fermentation;  and 
starchy  foods,  barring  wheat  flour,  sago,  macaroni,  toast,  farina,  and 
arrowroot,  which  are  the  least  harmful,  should  be  discontinued  or 
selected  with  care. 

In  order  that  the  inexperienced  practitioner  may  obtain  a  prac- 
tical idea  as  to  the  best  manner  of  arranging  the  diet  in  cases  of  entero- 
colitis complicated  by  diarrhea,  the  author  has  appended  the  list  of 
Cohnheim,  which  is  a  ven,-  good  one: 

7.00  A.  M.:    Mineral  water,  hot,  and  taken  in  small  doses  of  (25  to  5  oz. — 75- 

150  c.c).     The  choice  of  the  water  depends  upon  the  state  of  the 

gastric  secretions. 

7.30  .A..  M.:    Eichel  cocoa  (two  teaspoonfuls  to  a  ctrpj  in  water,  and  toasted  white 

bread  and  butter. 

'to.oo  A.  M.:    A  cereal  soup  ^\-ith  butter,  toast  with  butter,  eggs,  and  scraped  ham. 

1. 00  p.  M.:    Broth  ^\'ith  grits,  noodles,  macaroni,  and  white  meat;  in  rruld  cases, 

vegetable  purees  and  one  glassful  of  blueberr\"  wine. 
4.00  p.  M.:    Same  as  7.30  a.  m. 
6.00  p.  M.:    Mineral  water. 
7.00  to    8.00  p.  M.:    Tea  with  red  wine  or  blueberr\-  wine,  toast,  butter,  and  cold  white 

meat. 
9.00  to  10.00  p.  M.:    A  cupful  of  hot  peppermint-tea. 

In  mild  cases,  when  the  stool  is.  of  a  pulpy  consistency,  or  after 
impro\"ement  in  severe  cases,  white  bread,  carrots,  filet,  and  baked 
fish  may  be  allowed. 

Contra-indicated  Foods  and  Drinks. — Always  during  acute  crises 
and  usually  in  subacute  and  chronic  colitis  the  following  foods  should 
be  interdicted  or  cautiously  permitted,  particularly  when  diarrhea 
and  pain  are  persistent:  Raw  fruits  (oranges,  pears,  dates,  figs, 
bananas,  and  apples j ;  salads;  vegetables  (peas,  beans,  celery-,  cabbage, 
turnips,  cauliflower,  radishes,  green  corn,  mushrooms,  carrots,  onions, 
cucumbers,  potatoes,  etc.),  particularly  those  which  are  rich  in  cellu- 
lose or  favor  intestinal  fermentation  and  putrefaction;  spices,  salt; 
pastries.  r\e,  and  newly  baked  bread  containing  yeast,  sugar,  organic 
acids,  alcohol  (beer,  ale.  whisky,  and  sour  wines) ;  strong  tea  and 
coffee,  cold  and  carbonated  water,  lemonade,  ice-cream,  fats,  smoked 
and  insufficiently  cooked  meat  and  fish,  fried  and  hard-boiled  eggs, 
shell-fish.  gra\y,  and  starches. 

Massage  and  vibration  are  useful  adjuvants  in  the  treatment  of 
chronic  colitis  complicated  by  atrophy'  or  atony  of  the  bowel,  deficient 
intestinal  motility,  and  constipation,  because  they  encourage  glandular 
and  muscular  activity,  help  to  dislodge  impactions,  and  propel  the 


MEDICAL    TREATMENT  205 

feces  toward  the  anus.  Electricity  may  be  employed  for  similar  pur- 
poses, using  the  faradic  or,  preferably,  galvanic  current  (interrupted  or 
continuous),  and  applying  one  electrode  to  the  abdomen  or  spine 
and  introducing  the  other  into  the  bowel,  which  may  or  may  not  con- 
tain a  normal  saline  solution  to  conduct  the  electricity  to  the  upper 
colon. 

Hydrotherapy  is  a  more  useful  agent  than  the  above  physical 
measures,  and  the  water  may  be  used  internally  or  in  the  form  of 
showers,  Scotch  douches,  or  baths.  Cold  douches  and  baths  produce 
a  tonic  effect  upon  the  strong,  owing  to  the  remarkable  cutaneous  reac- 
tion which  follows  them,  but  are  harmful  to  weak  subjects  and  debil- 
itated patients  because  of  the  shock  which  follows  their  administra- 
tion, and  soothing  and  stimulating  ivarm  salt  or  needle-baths  should  be 
substituted  for  them.  The  Priessnitz  wet-pack  to  the  abdomen  is 
universally  recommended  in  the  treatment  of  enterocolitis,  because 
it  strengthens  the  viscera  and  abdominal  musculature,  besides  adding 
much  to  the  patient's-  comfort.  Cool  water  drinking  is  advantageous 
in  the  presence  of  constipation,  owing  to  its  tonic  effect  upon  the 
bowel,  but  the  water  should  be  drunk  as  hot  as  bearable  when  the 
intestine  is  irritable  or  the  patient  suffers  from  enterospasm  or  gas- 
pains. 

Mineral  waters  are  frequently  useful  in  the  treatment  of  chronic 
colitis,  but  their  employment  must  be  modified  to  meet  the  indica- 
tions in  mild  and  severe  types  of  colitis  and  in  the  presence  of  gastric 
derangements.  They  are  often  advertised  as  cures  for  intestinal 
catarrh  by  mineral  springs  companies  when  such  is  not  the  case, 
though  often  better  results  are  obtained  from  them  (in  watering-places) 
because  of  the  regime  enforced  upon  the  patient  while  there.  When 
there  is  a  deficiency  of  the  ingredients  composing  the  gastric  juice, 
waters  which  contain  sodium  chlorid,  such  as  Homburg,  Wiesbaden, 
Hawthorne,  and  Blue  Lick  Springs,  are  extremely  helpful,  particu- 
larly when  employed  with  other  therapeutic  measures;  but  when 
the  secretion  of  the  stomach  is  normal,  or  there  is  hyperchlorhydria, 
Carlsbad,  Marienbad,  Vichy,  or  French  Lick  Springs  water  is  indicated. 
These  and  similar  mineral  waters  are  more  effective  when  taken  upon 
an  empty  stomach  and  at  the  body  or  a  warmer  temperature,  and 
should  be  administered  in  smaller  amounts  to  depleted  than  to  strong 
individuals.  W'aters  of  this  class  are  contra-indicated  in  enterocolitis 
when  diarrhea  is  persistent  or  the  patient  suffers  from  cramps,  unless 
it  is  evident  that  the  bowel  contains  some  irritant  (dried  discharge, 
such  as  mucus,  scybalse,  etc.)  which  they  would  expel;  at  other  times 
they  afford  relief  whether  taken  by  mouth  or  used  in  the  form  of 
enemata  or  irrigations,  but  it  is  not  known  whether  their  beneficient 
action  is  due  to  their  alkaline  effect  upon  the  mucosa  or  chemical 
changes  which  take  place  in  the  gastro-intestinal  contents  through 
their  agency. 

Medical  Treatment. — Medicines,  except  when  intelligently  used, 
in  the  treatment  of  chronic  catarrhal  enterocolitis  do  a  great  deal  more 


206  ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

harm  than  good.  Drugs  should  be  employed  for  the  relief  of  symptoms 
rather  than  cure  of  the  disease,  and  ahvays  give  better  results  when 
used  in  conjunction  with  the  therapeutic  measures  previously  outlined 
than  when  prescribed  independently.  When  diarrhea  and  pain  are 
persistent  drugs  are  indicated  when  these  symptoms  cannot  be  over- 
come b>-  rest,  correcting  the  diet,  and  hot  fomentations,  but  opiates 
and  insoluble  agents,  like  bismuth,  should  be  cautiously  administered, 
because  the  first  may  lead  to  the  drug  habit  and  the  second  to  the 
formation  of  bismuth  enteroliths,  which  sometimes  remain  in  the  bowel 
indefinitely  and  intensify  the  patient's  suffering  or  cause  obstruction, 
as  has  been  witnessed  by  the  author  in  a  number  ot  instances. 

Where  patients  are  very  ner^^ous  or  greatly  depleted.  Fowler's 
solution  of  arsenic,  gtt.  ij  to  x  (0.12-0.60),  Blaud's  pills,  carbonated 
guaiacol,  gr.  x  (0.60),  or  a  reliable  iron  preparation  should  be  included 
in  the  treatment  to  improve  the  patient's  general  condition. 

Antiseptic,  soothing,  and  astringent  remedies  which  diminish  the 
intestinal  secretions,  irritability  of  the  mucosa,  fermentation,  putre- 
faction, and  peristaltic  activity,  favor  solidification  of  the  feces  and 
tend  to  minimize  diarrhea  and  pain,  such  as  bismuth  preparations, 
gr.  X  to  XX  (0.6-1.3);  uzara,  gtt.  xxx  (2.0);  creosote,  gtt.  j  to  x 
(0.06-0.60);  beta-naphthol,  gr.  v  (0.30);  salol,  gr.  v  to  x  (0.30-0.60); 
boric  acid,  gr.  iv  (0.24);  tannigen,  tannalbin,  or  tannopin,  gr.  v  to  xv 
(0.3-1.0);  ichthalbin,  gr.  x  to  xx  (0.6-1.3);  fortoin,  gr.  iv  (0.24),  etc., 
administered  three  or  more  times  daily,  according  to  indications,  do 
much  toward  relieving  the  patient's  distress,  quieting  the  inflam- 
matory process  and  healing  ulcers  within  the  bowel.  Methylene- 
blue  (10  eg.)  is  a  reliable  remedy  to  employ  in  connection  with  lac- 
tose when  diarrhea  is  persistent.  When  it  is  desirable  to  administer 
a  remedy  which  will  protect  the  inflamed  mucosa,  calcium  carbonate 
or  phosphate,  chalk  or  charcoal,  gr.  xv  (i.o),  three  or  four  times  daily, 
alone  or  in  conjunction  with  oli\"e  oil,  nutralol,  or  petroleum,  5]  (30.0), 
give  the  best  results. 

When  other  measures  fail  to  relieve  the  patient's  diarrhea  and 
pain,  opium  is  the  remedy  par  excellence,  independently  or  combined 
with  the  above-mentioned  drugs.  Quickest  relief  follows  when  it  is 
administered  in  the  form  of  morphin,  gr.  |  to  |  (0.0008—0.015),  but 
when  there  is  no  occasion  for  haste,  opium  extract,  gr.  |  (0.03),  or  tinc- 
ture, gtt.  V  to  x  (0.30-0.60),  codein,  gr.  j  (0.015),  or  heroin,  gr.  ^V 
(0.006),  administered  according  to  indications,  invariably  relieve  pain, 
minimize  the  diarrhea,  and  enable  the  patient  to  sleep. 

When  complications  are  present  in  addition  to  the  abo\e,  other 
remedies  are  indicated,  viz.,  in  anorexia,  nux  vomica;  hyperchlorhydria, 
an  alkali  or  dilute  nitric  acid;  anemia,  iron  preparations ;_//a///5,  sulpho- 
carbonate  of  zinc;  hyperacidity  with  constipation,  powdered  magnesia 
or  cooking-soda;  enterospasm,  belladonna,  etc.,  and  should  be  adminis- 
tered in  suitable  doses  as  often  as  required. 

Calomel  and  soda,  of  each  gr.  \  (0.03),  administered  half-hourly 
until  3  gr.  have  been  taken,  is  the  most  reliable  agent  to  employ  when 


IKKICiATIOXS  207 

the  patient  is  bilious,  suffers  from  intestinal  toxemia,  or  there  is  an  irri- 
tant in  the  bowel  to  be  expelled,  when,  on  the  following  morning,  a 
saline  is  taken  to  carry  it  off. 

Constipation  can  usually  be  controlled  by  the  saline  mineral 
waters,  3ss  to  j  (15-30),  previously  mentioned;  Carlsbad,  gr.  xxx 
(2.0);  Epsom,  Glauber's,  or  Rochelle  salts,  5j  to  ij  (4-8  c.c),  tw^o  or 
three  times  daily,  are  preferable  to  other  laxatives  because  of  their 
beneficent  action  upon  the  intestinal  mucosa.  Enemata  of  olive, 
sweet,  almond,  or  mineral  oil  when  injected  warm  usually  secure  an 
immediate  evacuation,  or  a  10  per  cent,  solution  of  gelatin,  5j  to  ij 
(30-60  c.c),  which  is  particularly  soothing  to  the  inflamed  bowel, 
may  be  substituted  for  the  oil. 

Irrigations. — Bowel  flushings  with  normal  saline  and  other  medi- 
cated solutions  are  beneficial  in  the  treatment  of  chronic  catarrhal 
colitis  and  enterocolitis,  because  they  rid  the  gut  of  irritating  toxins, 
undigested  food  remnants,  hardened  fecal  masses,  foreign  bodies  and 
offensive  bacteria,  reduce  inflammation,  heal  ulcers,  and  supply  the 
bowel  with  additional  water  when  there  is  exhaustive  diarrhea.  Oc- 
casionally cold  irrigations  (65°  F.)  are  agreeable,  but,  as  a  rule,  entero- 
clysis  is  more  effective  when  employed  warm  or  hot  (110°  to  120°  P.), 
because  hot  solutions  are  soothing,  retained  longer,  allay  nervous- 
ness, diminish  pain,  and  make  the  bowel  feel  more  comfortable. 
Once  daily  or  three  times  weekly  is  sufificient  in  ordinary  cases  of 
catarrhal  enterocolitis,  but  the  bow^el  should  be  thoroughly  flushed 
morning  and  night  when  the  mucosa  is  ulcerated,  there  is  a  mixed 
infection,  and  pus,  blood,  and  mucus  collect  quickh'. 

There  are  no  specific  irrigants,  and  the  usefulness  of  medicated 
bowel  washings  should  be  attributed  more  to  the  healing  and  mechan- 
ical actions  of  the  solution,  in  getting  rid  of  irritating  debris  and  cur- 
ing ulcers,  than  to  the  specific  action  of  the  remedy.  The  amount  of 
fluid  employed  should  vary  from  a  few^  ounces  to  4  quarts,  depending 
upon  the  extent  of  the  catarrhal  inflammation  and  accompanying 
changes,  but  more  copious  irrigation  and  injections  are  to  be  avoided, 
because  they  distend  and  cause  the  bowel  to  sag,  induce  pain,  and  may 
cause  perforation,  except  when  used  through  a  double-flow  irrigating 
tube.  It  is  essential  that  the  position  of  the  patient  be  frequently 
changed,  so  that  all  parts  of  the  intestinal  mucosa  are  reached  during 
the  irrigation. 

(iood  results  are  obtainable  in  this  class  of  cases  from  normal  saline 
or  boric  acid  (3  per  cent.),  ichthyol  (2  per  cent.),  balsam  of  Peru  (i 
per  cent.),  permanganate  of  potassium  (i  per  cent.),  protargol  or  argy- 
rol  (5  per  cent.),  or  silver  nitrate,  gr.  v  to  Oij  (0.30  gm.  to  looo  c.c), 
solutions,  introduced  through  the  appendix,  cecum,  or  anus. 

Better  results  can  sometimes  be  obtained  by  alternating  the  irri- 
gations with  copious  enemata  Oj  (500)  of  warm,  olive,  cotton-seed, 
or  mineral  oil  alone  or  containing  bismuth,  aristol,  salol,  5ij  (8.0), 
etc..  which  soothe  and  orotect  the  inflamed  mucosa  and  augment 
healing. 


208  ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

Surgical  Treatment. — Surgical  measures  are  less  often  called 
for  in  the  treat nient  of  enteritis  and  colitis  than  in  the  infectious  types 
of  colitis,  but  when  the  bowel  is  extremely  irritable,  eroded  or  ulcer- 
ated, or  the  patient  suffers  from  mixed  infection  and  other  therapeutic 
measures  fail,  it  may  be  necessary  to  resort  to  appendicostomy,  cecos- 
tomy,  or  Gant's  enterocecostomy,  procedures  which  enable  one  to  put 
the  bowel  more  or  less  at  rest  and  to  practice  daily  through-and- 
through  irrigation.  For  a  further  description  of  the  indications  and 
technic  of  these  operations,  the  reader  is  referred  to  the  chapters 
devoted  to  the  surgical  treatment  of  catarrhal,  diarrheal,  and  parasitic 
affections  of  the  gastro-intestinal  tract. 

Opotherapy  and  organotherapy  have  been  employed  with  some  suc- 
cess by  others  in  the  treatment  of  chronic  catarrhal  and  infectious  en- 
terocolitis, but  the  author  has  not  employed  them  sufficiently  to  war- 
rant recommending  them  in  this  class  of  cases.  Intestinal  extracts  and 
secretin  (0.05)  have  also  proved  helpful  in  the  treatment  of  chronic 
catarrhal,  tubercular,  dysenteric,  and  mucomembranous  enterocolitis, 
constipation,  and  biliousness,  but  sometimes  they  irritate  the  intes- 
tinal mucosa  and  must  be  stopped.  Pancreatic  opotherapy  is  said 
to  be  useful  alone  or  in  conjunction  with  secretin  when  diarrhea  is 
consequent  upon  pancreatic  affections,  nervous  phenomena,  and 
colitis  with  intolerance  to  milk. 

Vaccines. — The  usefulness  of  vaccines  in  the  treatment  of  typhoid 
fever  has  been  established  beyond  question,  and  sera  have  proved 
effective  in  cases  of  bacillary,  but  not  in  entamebic,  colitis.  In  the 
two  former  the  causative  organisms  liberate  endotoxins  following 
autolysis,  enabling  one  to  manufacture  a  reliable  therapeutic  agent 
which  minimizes  or  arrests  the  infective  process,  but  the  remedy,  owing 
to  its  toxicity,  should  be  administered  with  caution. 

Vaccines  have  been  prepared  from  BaciHus  coli  communis  and 
coliform  bacilli  by  Hale  White  and  Eyre,  and  used  with  some  suc- 
cess in  the  treatment  of  the  class  of  diseases  under  discussion. 

The  bolus  or  clay  treatment  introduced  by  Stumpf  is  highly  recom- 
mended by  Gaertner  in  gastro-intestinal  affections  complicated  by 
diarrhea  and  meteorism,  because  of  its  inhibitive  action  upon  bacterial 
growth,  particularly  when  the  clay  (bolus  alba)  is  given  upon  an  empty 
stomach,  and  in  doses  varying  from  3iss  to  iijss  (50-100)  in  \  pint 
(250  c.c.)  of  water.  It  has  been  found  particularly  useful  in  chronic 
catarrhal  and  tubercular  bowel  diseases,  and  for  protecting  patients 
exposed  to  typhoid  and  those  about  to  be  operated  upon  against 
infection. 

The  Rosenberg  dry  treatment  has  been  successfully  employed  by 
the  author  in  proctitis  and  sigmoiditis,  but  the  method  is  useless  in 
the  treatment  of  colitis,  because  the  powder  cannot  be  applied  to  the 
entire  large  bow^el  except  following  the  author's  enterocecostomy. 
Rosenberg  considers  it  superior  to  other  methods  of  treatment,  owing 
to  the  prolonged  action  of  the  remedy,  which  clings  for  hours  follow- 
ing its  application  to  the  inflamed  or  ulcerated  mucosa.     The  powder 


PROGNOSIS    OF    ENTERITIS,    COLITIS,    AND    ENTEROCOLITIS         209 

may  be  applied  with  swabs,  but  the  author  prefers  to  place  the  patient 
in  the  knee-chest  posture,  insert  the  sigmoidoscope,  inflate  the  bowel, 
and  then  introduce  the  remedy  through  a  powder-blower  and  wdth 
the  aid  of  compressed  air  continuing  the  application  until  the  mucosa 
is  covered  with  the  powder.  Such  a  treatment  minimizes  pain,  lessens 
tenesmus,  and  assists  in  healing  the  lesions,  but  the  author  considers 
both  topical  applications  and  medicated  irrigation,  as  outlined  above, 
more  effective  than  Rosenberg's  remedy,  which  is  composed  of  tannic 
acid  and  magnesium,  though  bismuth,  xeroform.  and  zinc  are  some- 
times employed. 

Rosenberg's  Powder: 

^.     01.  thymi 4  c.c; 

Acid,  tannic 15  gm.; 

Magnes q.  s.  ad  100   "     — M. 

Clifton  Springs  Pack. — This  abdominal  pack,  which  is  composed 
of  equal  parts  of  mustard,  red  pepper,  and  prickly  ash  bark,  thoroughly 
mixed,  is  a  valuable  agent  for  relieving  pain  and  discomfort  and  cjuiet- 
ing  peristalsis  during  diarrheic  crises  on  account  of  its  moisture  and 
counterirritant  action.  It  is  applied  by  putting  a  tablespoonful  of 
the  mixture  in  a  quart  of  warm  w'ater,  saturating  flannel  cloths  in  the 
solution,  and  placing  them  over  the  abdomen.  In  the  absence  of  the 
pack,  hot  turpentine  stupes  may  be  substituted. 

The  Fani^o  and  similar  compresses  are  useful  in  some  instances. 

Inflation  of  the  intestine  with  oxygen  has,  in  the  author's  hands, 
proved  a  valuable  adjunct  to  the  treatment,  because  it  immediately 
braces  the  patient  up,  improves  his  anemic  condition,  augments 
peristalsis  (w'hen  constipation  prevails),  increases  intestinal  disinfec- 
tion, and  augments  the  amount  of  oxygen  in  the  blood.  Oxygen  can 
be  easily  introduced  into  the  alimentary  tract  through  tubes  connected 
with  a  tank  passed  into  the  stomach  and  rectum.  A.  Schmidt  com- 
bines a^ar  (oxyagar)  and  insufflates  2  to  4  quarts  (liters)  twice  daily 
through  Einhorn's  duodenal  tube,  w^hich  is  followed  by  an  odorless 
flatus,  and  later  by  diminished  intestinal  fermentation  and  putrefac- 
tion. Carbonic  acid  gas,  introduced  through  the  rectum,  has  been 
frequently  employed  in  the  treatment  of  intestinal  catarrh  by  A.  Rose, 
who  claims  that  its  effects  are  stimulating,  strengthening,  and  antisep- 
tic. The  author  has  employed  the  method  in  a  few  instances  with 
disappointing  results,  and  has  abandoned  it,  owing  to  the  distention 
pains  which  accompany  and  follow  the  treatment. 

Prognosis  of  Enteritis,  Colitis,  and  Enterocolitis. — Adults  usually 
suffer  considerable  annoyance  and  discomfort  from  acute  catarrhal 
enteritis,  colitis,  or  enterocolitis,  but  recover  in  a  few  days  or  weeks, 
except  in  complicated  cases,  where  the  disease  becomes  chronic. 
Infants,  very  young  children,  the  aged,  and  enfeebled  indi\iduals 
often  become  greatly  exhausted  and  frequently  succumb  to  it  unless 
carefully  handled. 

Chronic  intestinal  catarrh  is  distressing,  greatly  debilitates  the 
14 


210  ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    xN 

patient,  and  frequently  incapacitates  him  for  business  and  social 
duties,  and,  when  neglected  or  ignorantly  treated,  death  may  ensue 
from  mental  and  physical  exhaustion.  This  affection  rarely  causes 
death  directly,  but  occasionally  it  is  responsible  for  the  patient's  end, 
because  it  sucks  his  vitality  and  gets  the  intestinal  mucosa  inflamed 
and  eroded,  conditions  which  pave  the  way  for  constitutional  and  local 
infectious  and  other  diseases  having  much  higher  mortality  than 
catarrhal  enterocolitis.  As  a  rule,  under  favorable  conditions,  acute 
intestinal  catarrh  subsides  in  a  few  days  or  weeks,  and  chronic  abates 
in  a  few  months,  when  the  patient  is  protected  against  exposure, 
arduous  labor  and  unhealthy  surroundings,  is  properl}'  clothed,  fed, 
treated,  and  placed  in  the  midst  of  cheerful  surroundings  to  improve 
his  despondency. 


CHAPTER   XIX 

TUBERCULAR   ENTERITIS,  COLITIS,   AND   ENTEROCOLITIS 
(INTESTINAL   TUBERCULOSIS),   DIARRHEA  IN 

GENERAL  REMARKS,   ETIOLOGY 

General  Remarks. — Clinicians  at  all  familiar  with  intestinal  affec- 
tions concede  that  tuberculosis  is  an  important  factor  in  diarrliea  he- 
cause  of  its  frequency  as  a  cause,  and  the  difficulty  encotmtered  in 
relieving  or  curing  this  type  of  loose  movements. 

The  frequent  ev^acuations  of  tubercular  subjects  may  be  excited 
by  tuberculosis  of  the  bowel  or  an  intestinal  catarrh  which  preceded 
or  made  its  appearance  simultaneously  with  phthisis  or  tubercular 
infection  in  the  bowel  or  elsewhere.  The  comprehensive  statistics 
hereafter  (] noted  relative  to  postmortems  held  upon  persons  suffering 
from  this  disease  show  that  the  bowel  is  usually  affected  by  a  simple 
enteritis  (most  common)  or  tubercular  lesions  of  the  intestine,  either 
of  which  arc  sufficient  to  account  for  the  loose  movements  so  frequently 
complained  of  by  tubercular  subjects,  irrespective  of  where  the  dis- 
ease is  located. 

Relative  Frequency  of  Tuberculosis  in  Different  Parts  of  the  Intes- 
tine.— All  segments  of  the  intestine  are  liable  to  tubercular  infection, 
but  some  parts  of  the  bowel  are  more  frequently  affected  than  others. 
Statistics  bear  out  the  author's  personal  observations  that  the  lower 
half  of  the  small  bowel  is  very  much  more  often  attacked  by  tuber- 
culosis than  the  upper,  the  cecum  is,  in  the  vast  majority  of  cases,  the 
favorite  location,  and,  next  to  the  ascending  colon,  the  anorectal 
region  is  more  frequently  the  seat  of  foci  than  other  portions  of  the 
large  bowel. 

Xikoljski,  in  120  operations  and  70  autopsies  performed  upon 
persons  suffering  from  tubercular  intestinal  stricture,  rarely  found  the 
stenoses  in  the  upper  small  intestine  or  colon,  but  encountered  them 
frequently  in  the  lower  ileum  or  cecum,  while  Caird  (i  i  cases)  observed 
them  at  the  ileocecal  valve  and  cecum  in  6,  in  the  small  intestine 
alone  in  4,  and  the  ascending  colon  in  i  case.  Eisenhardt's  statistics 
show  tuberculosis  of  the  small  intestine  in  83,  and  of  the  large  bowel 
in  135  cases,  but  does  not  indicate  the  segments  of  gut  involved. 
In  Eisenbach's  collection  of  tubercular  infections,  the  disease  was 
located  in  the  small  bowel  nine  times,  cecum  twenty-seven,  and  the 
descending  colon  and  api^endix  each  once.  Reach  cites  Strehl's  unique 
case  of  multiple  strictures,  fourteen  of  which  were  located  in  the  ileum 
and  the  other  in  the  hepatic  flexure. 

The  most  elaborate  and  extensiveh'  (luoled  statistics  relating  to 
this  subject  are  those  of  Fenwick  and  Dodwell,  who,  in  2000  autopsies 
performed  upon  tubercular  subjects,  found  infection  of  the  intestine 

211 


212     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS.    DIARRHEA    IN 

in  883  cases.  The  lesions  were  located  in  the  different  parts  of 
the  bowel  in  conjunction  with  other  segments  or  alone  as  follows: 
Duodenum,  3.4  per  cent.;  alone,  none;  jejunum,  28 — 1.4  per  cent.; 
ileum,  60.2 — 4.4  per  cent.;  ileocecal,  85 — 9.6  per  cent.;  appendix,  50 — 
3.8  per  cent.;  ascending  colon,  51.4 — 1.8  per  cent.;  transverse  colon, 
30.6 — I  per  cent.;  descending  colon,  21.0  per  cent. — none;  sigmoid 
flexure,  13.5  per  cent. — none;  rectum,  14. i  per  cent. — none. 

The  duodenum  is  seldom  involved  in  the  tubercular  process,  but 
when  it  is  the  stomach  is  frequently  diseased.  The  author  has  been 
unable  to  find  many  reported  cases  of  duodenal  tuberculosis,  and  of 
these  Maylard  mentions  3.  In  the  first  the  duodenum  and  pan- 
creas were  massed  together  with  tubercular  caseous  glands,  in  the 
second  there  was  a  large  transverse  ulcer,  and  in  the  third  a  small 
round  ulcer  with  thickened  edges,  |  inch  (1.25  c.c.)  distant  from  the 
pylorus  and  the  tubercles,  involved  the  peritoneum.  Hamilton  has 
recorded  a  case  in  connection  with  gastric  tuberculosis  of  a  large  ulcer 
at  the  pyloric  extremity  of  the  duodenum,  the  base  of  which  was 
covered  with  tubercles.  Mayo  Robson  has  called  attention  to  a  case 
of  duodenal  tubercular  stricture  discovered  while  performing  pyloro- 
plasty upon  a  young  girl.  Reach  observed  but  one  instance  of  duod- 
enal involvement  in  21  collected  cases  of  multiple  intestinal  tubercular 
stricture,  and  this  patient  suffered  from  the  disease  in  other  parts  of 
the  intestine. 

The  author  has  encountered  tuberculosis  of  the  duodenal  mucosa 
in  only  two  instances,  but  he  has  observed  its  peritoneal  covering 
freely  studded  with  tubercles  and  the  muscular  tunic  appeared  to  be 
involved  in  other  cases.  In  the  first  instance  the  tubercles  were 
limited  to  the  duodenum,  but  in  the  other  they  extended  over  the 
entire  small  intestine  and  covered  the  cecum. 

Jejunal  tuberculosis  is  more  frequent  than  duodenal,  but  the  disease 
does  not  occur  here  so  frequently  as  in  the  ileum.  White  gives  two 
sets  of  statistics  of  bowel  tuberculosis  complicating  phthisis — in  the 
first  series  (57  cases)  the  jejunum  was  involved  7  and  the  ileum  32 
times,  while  in  the  second  (66  cases),  tuberculosis  occurred  in  the 
jejunum  20  (30.3  per  cent.)  and  in  the  V/cz^w  36  times  (54.5  per  cent.), 
but  in  the  remaining  10  cases  its  location  was  not  given.  These  last 
figures  do  not  differ  materially  from  those  of  Fenwick  and  Dodwell, 
who  state  that  the  jejunum  was  involved  in  the  tubercular  process  in 
28  per  cent,  of  the  cases.  Mikulicz  has  recorded  3  cases  of  jejunal 
stricture,  including  one  of  his  own,  and  Reach  has  recorded  another. 

The  upper  ileum  is  not  much  more  frequently  attacked  by  tuber- 
culosis than  the  distal  end  of  the  jejunum,  but  its  lower  extremity 
very  often  becomes  involved  because  of  frequent  extension  of  the  dis- 
ease upward  from  the  cecum  (Fig.  27).  Hemmeter  examined  the 
intestines  of  56  persons  who  died  of  phthisis,  and  in  14  instances  tuber- 
cular ulcers  were  observed  in  the  ileum  and  colon. 

Alglave,  in  the  28  cases  of  granular  ulcerative  tubercular  lesions 
of  the  bowel,  found  10  simultaneous  lesions  of  the  ileum,  cecum,  and 


PREDISPOSING    CAUSES    OF    INTESTINAL    TUBERCULOSIS 


213 


«!r^ 


>A 


fm 


appendix,  6  simultaneous  lesions  of  the  ik-uni  and  cecum  without 
lesion  of  the  appendix,  7  lesions  of  the  ileum  without  involvement  of 
the  cecum  or  appendix,  i  case  of  simultaneous  lesion  of  the  cecum 
and  appendix  without  lesion  of  the  ileum,  3  lesions  of  the  cecum  with- 
out involvement  of  ileum  or  appendix,  i  case 
of  lesion  of  the  appendix  without  lesion  of 
cecum  or  ileum.  In  other  words,  in  23  of 
the  28  cases  the  ileum  was  exclusively  af- 
fected in  7  cases,  in  20  of  28  cases  the  cecum 
was  diseased  (3  times  exclusively),  and  in 
12  of  28  cases  the  appendix  w^as  afifected 
(once  exclusively). 

The  cecum  is  very  freciuenth-  invohed  in 
cases  of  pulmonary  tuberculosis,  and  in  in- 
testinal tuberculosis  the  disease  is  located  at 
the  cecum  very  much  more  frequently  than 
in  the  remainder  of  the  bowel,  and  all  forms 
of  the  disease  are  encountered  in  this  region. 
Fenwick  and  Dodwell  found  the  cecum  in- 
volved in  85  per  cent,  of  all  cases,  and  in 
9.6  per  cent,  of  the  cases  the  disease  was 
limited  exclusively  to  this  region. 

Alglave  says  the  enteroperitoneal  form  of 
intestinal  tuberculosis  is  peculiar  to  the  ileo- 
cecal region,  and  that  when  other  parts  of 
the  intestine  are  involved  the  lesions  cen- 
tralize in  and  adjacent  to  the  cecum.  Re- 
garding the  hypertrophic  or  neoplastic  type, 
he  states  that  it  may  occur  in  any  part  of 
the  intestine,  Vjut  its  seat  of  predilection  is 
the  ileocecal  angle. 

To  indicate  the  frequency  of  the  tubercu- 
lar process  in  this  region  the  author  will  cite 
the  statistics  of  two  authorities  whose  names 
are  most  prominently  associated  with  cecal 
tuberculosis.  Hartmann  has  collected  299 
operations  for,  and  Campieche  has  recorded 

379  cases  of,  ileocecal  tuberculosis,  and  there  are  many  other  scattered 
cases.  These  statistics,  with  others  which  could  be  added,  demon- 
strate conclusively  that  tuberculosis  attacks  the  ileocecal  angle  more 
frequently  than  any  other  segment  of  the  bowel. 


.^^ 


i3t 


I  :^'.  _;.  --;....^.  „nd  large 
enteric  girdle  cicatrizing  tu- 
bercular ulcers  of  the  ileum. 


ETIOLOGY 

Predisposing  Causes  of  Intestinal  Tuberculosis. — Intestinal  tuber- 
culosis may  occur  in  otherwise  healthy  individuals,  but  is  most  often 
encountered  in  persons  who  have  a  hereditary  tendency  to  the  dis- 
ease, arduous  occupations  or  those  which  subject  them  to  exposure, 
poor  food,  or  insufficiently  ventilated  rooms  and  unhygienic  surround- 


214     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 


ings,  conditions  which  lower  their  resistance  and  render  them  Hable  to 
infection  by  tubercle  bacilli  and  other  infectious  agents. 

Bowel  tuberculosis  has  freciuenth'  been  traced  to  affections  of  the 
gastro-intestinal  tract  accompanied  by  inflammation  or  ulceration  of 
the  mucosa  and  irritating  discharges,  and  a  sufficient  number  of 
cases  of  tuberculosis  secondary  to  trauma  have  been  recorded  to  war- 
rant the  belief  that  the  traumatism  which  ensues  in  consequence  of 
surgical  operations,  constipation  and  recurring  impaction,  in\agina- 
tion,  ptosis,  angulation  or  twisting  of  the  bowel,  pressure  upon  or 
irritation  to  the  gut  induced  by  tumors  or  disease  in  neighboring 
organs,  tend  to  interfere  with  the  bowel  and  pave  the  way  for  tubercu- 
lar infection.  Young  bottle-fed  children  are  predisposed  to  intestinal 
tuberculosis  more  frequently  than  adults  because  of  the  food  con- 
sumed and  the  prevalence  among  them  of  diarrhea,  constipation,  and 
other  bowel  affections. 

Age. — Intestinal  tuberculosis  may  occur  at  almost  any  time 
from  infancy  to  old  age.  The  author  has  treated  a  girl  of  three  for 
enteric  tuberculosis,  a  man  of  seventy  for  the  neoplastic  type,  and 
other  patients  of  various  ages,  young  and  old.  Nevertheless,  age  is 
an  important  factor  in  intestinal  tuberculosis,  as  is  evidenced  by  the 
statistics  upon  the  subject.  Practically  all  authorities  agree  that  this 
affection  in  its  different  forms  occurs  far  more  frequently  in  persons 
betwxeri  twenty  and  forty  years  of  age,  and  especially  in  the  third 
decade,  than  at  any  other  time,  and  the  writer's  observations  corrobo- 
rate these  views. 

Primary  tuberculosis  is  encountered  most  often  in  young  children, 
and  the  neoplastic  type  in  older  persons.  The  following  table,  repre- 
senting the  statistics  of  Crowder,  illustrates  very  well  the  relative  fre- 
quency with  which  tuberculosis  of  the  intestine  occurs  in  the  various 
stages  of  life  and  the  frequency  with  which  both  sexes  are  attacked. 


Age. 

Male. 

Female. 

Total. 

I   to  lO 

0 

4 
10 

19 
3 
3 

0 
7 
14 
10 
6 
5 

0 

II  to  20 

21   to  30 

31  to  40 

41  to  SO 

51  to  60 

II 

24 
29 

9 
8 

Sex. — The  sex  is  of  no  etiologic  importance  in  intestinal  tubercu- 
losis, and  the  different  types  of  the  disease  seem  to  affect  men  and 
women  with  about  equal  frequency,  though  in  the  author's  experience 
the  male  sex  has  slightly  predominated,  as  was  the  case  in  Nikojski's 
170  collected  cases  of  tubercular  intestinal  stricture.  In  Esenbach's 
series  of  27  cases  of  intestinal  tuberculosis  there  were  13  men  and  14 
women,  while  in  Hartmann's  217  collected  operated  cases  of  ileocecal 
hyperplastic  tuberculosis  there  were  105  males  and  112  females. 

Method  of  Infection  in  Intestinal  Tuberculosis. — Tuberculosis 
of  the  intestine  iiuariably  results  from  the  iinasion  of  its  tunics  by 


METHOD    OF    INFECTION    IN    INTESTINAL    TUBERCULOSIS  21$ 

tubercle  bacilli.  Usually  the  tubercular  i)r(jcess  is  dui-  to  human 
tubercle  bacilli,  but  it  may  be  caused  by  bovine  bacilli  ftypus  boxinus). 
A  great  deal  of  discussion  was  excited  by  Koch  at  the  British  Medical 
Congress,  London,  1901,  when  he  made  the  statement  that  bovine 
tubercle  bacilli  were  different  from  the  human,  and  that  it  was  doubtful 
if  they  are  communicable  to  man.  Investigations  were  started  shortly 
thereafter  to  determine  the  nature  of  typus  hovinus  and  the  extent  to 
which  it  would  cause  tuberculosis  in  human  beings,  and  the  earlier 
experiments  and  observations  tended  to  support  the  theory  of  Koch, 
for  the  bovine  bacillus  was  rarely  discovered  in  tubercular  manifesta- 
tions of  adults  or  children,  but  when  found  it  was  encountered  most 
freciuenlly  in  tuberculosis  of  the  intestines  and  mesenteric  glands. 

(gradually  evidence  has  been  accumulating  which  disproves  the 
views  of  Koch,  and  demonstrates  beyond  question  that  tuberculosis 
of  the  intestine  and  elsewhere  can  be  contracted  from  the  milk  and 
meat  of  tuberculous  animals.  While  it  is  now  generally  agreed  that 
the  bo\ine  bacillus  can  cause  the  disease  in  man,  the  best  authorities 
concede  that  the  tuberculous  process  is  caused  by  human  bacilli  in 
the  majority  of  cases. 

In  intestinal  and  other  forms  of  tuberculosis,  bacilli  may  gain  access 
to  the  body  through  the  inhalation  of  contaminated  dust,  being  car- 
ried to  the  mouth  by  the  fingers,  toys,  walking  sticks,  pencils,  and 
other  objects,  the  ingestion  of  milk,  cream,  cheese,  butter,  meat,  or 
other  kinds  of  infected  edibles,  or  scratching  of  the  anus. 

While  food  products  are  known  to  occasionally  be  the  carr>'ing 
agents  of  tubercle  bacilli  (primary  tuberculosis),  it  is  a  fact  that  intes- 
tinal tuberculosis  is  secondary  to  and  caused  by  the  swallowing  of 
tubercle  bacilli  from  lesions  in  the  lungs,  larynx,  nasopharynx,  esopha- 
gus, stomach,  liver,  or  diseased  gut  higher  up  in  the  vast  majority  of 
cases,  and  it  has  been  shown  that  tubercle  bacilli  can  pass  through  the 
stomach  and  infect  the  intestine.  Because  of  the  infrequency  with 
which  tuberculosis  is  encountered  in  the  stomach,  jejunum,  and  upper 
ileum,  it  would  appear  that  the  gastric  juice  (hydrochloric  acid)  in 
some  way  attenuates  the  bacilli  temporarily,  and  that  they  regain  \iru- 
lence  after  having  reached  the  cecum  and  colon,  where  the  disease  is 
most  common,  and  propulsion  through  the  bowel  is  slow,  or  the  stasis 
common  to  this  region  favors  their  pathogenic  development. 

The  direction  from  which  the  bacilli  come  varies  in  different  cases. 
Ordinarily  they  gain  entrance  to  the  gut,  attack  the  mucosa,  and  the 
tubercular  process  extends  outward,  but  in  rare  instances  the  peri- 
toneal coat  first  becomes  invoked  through  extension  of  the  disease 
from  the  mesenteric  glands,  tubercular  organs,  or  infected  lymph  or 
blood.  Astute  observers  hold  that  human  and  bovine  tubercle  bacilli 
may,  under  favorable  conditions,  penetrate  the  healthy  or  diseased 
intestine  and  infect  neighboring  lymph-nodes  or  other  structures  ad- 
jacent to  or  distant  from  the  bowel. 

While  it  is  admitted  that  tubercle  bacilli  may  possibly  pass  through 
healthy  bowel,  all  agree  that  such  occurrences  are  rare,  and  that  when 


2l6     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 


they  penetrate  the  gut  or  find  their  \va\-  into  its  circulation,  tlie  mucosa 
has  already  been  denuded  of  its  epithelial  lining  by  erosions  or  ulcers. 
Fiaden  and  Schottelius  fed  animals  tubercular  material;  infection  of 
the  mesenteric  glands  and  other  parts  ensued,  which  would  indicate 
that  tubercle  bacilli  do  find  their  way  through  the  bowel  and  produce 
tubercular  foci  in  other  parts. 

Since  bovine  bacilli  apparenth'  can  infect  human  beings,  and  find 
their  way  through  the  normal  and  diseased  intestine  to  other  struc- 
tures, it  would  seem  that  they  might  be  responsible  for  the  primary 
tuberculosis  of  the  mesenteric  lymph-nodes,  intestine,  and  elsewhere. 

Instances  of  primary  intestinal  tuberculosis  have  been  reported 
without  autopsy  findings,  where  the  diagnosis  was  based  upon  the 
history,  general  and  local  examination,  and  absence  of  tuberculosis 
elsewhere,  or,  when  present,  where  it  occurred  secondary  to  bowel 
involvement  or  was  induced  by  extension  of  the  intestinal  infection 
by  contiguity  or  otherwise.  Such  reports  should  be  looked  upon  with 
skepticism,  because  primary  intestinal  tuberculosis  can  be  diagnosed 
by  autopsy  only  and  w4iere  tubercular  processes  elsewhere  have  been 
excluded. 

It  is  not  definitely  known  whether  bowel  tuberculosis  is  ever  in- 
herited or  not,  but  in  2  or  3  cases  the  disease  has  been  observed  in 
children  varying  in  age  from  a  few"  days  to  three  weeks  old,  born  of 
tubercular  parents,  and  one  is  justified  in  assuming  that  the  disease 
may  be  congenital. 

AUTHOR'S  TABLE  SHOWING  THE  FREQUENCY  WITH  WHICH  INTESTINAL 
TUBERCULOSIS   CO^SIPLICATES   THE   DISEASE   ELSEW^HERE 


Name. 

Number  of  tubercular 
cases. 

Percentage  complicated  with 
intestinal  tuberculosis. 

White  (Phipps  Institute) 

266 

883 

462 
1226 
1000 

290 
Niunber  not  stated 

963 
Number  not  stated 

a             (<             a 

45-1 
56.6 
21.9 
51.0 
56.6 
40.7  (children) 

Fen  wick  and  Dodwell 

Eichhorst 

Heinze 

Eisenhardt  (by  Crowder) 

Maylard  (collected) 

Zahn  (Osier) 

63.21 
47.0 

Grosser  (Osier) 

Baginsky 

All  intestinal  tubercu- 

Honing (Comet) 

losis  secondary 
70.0 

Weigert  and  Orth  (Cornet) 

90.0 

Total 

5090 

49.27 

Excluding  the  statistics  of  Honing  and  Weigert  and  Orth,  the 
average  percentage  is  42.45  per  cent.  Herxheimer,  quoted  by  Crowder, 
states  that  of  58  cases  of  intestinal  tuberculosis,  98.2  per  cent,  were 
secondary.  In  100  cases  of  intestinal  tuberculosis  (ulcers,  catarrh, 
fistula,  abscesses,  etc.)  observed  by  the  author,  tuberculosis  developed 
in  the  bowel  secondary  to  the  disease  elsewhere  (lungs,  70  per  cent.) 
in  75  per  cent,  of  the  cases. 


I'KI.MARV    AND    SI-XOXDARY    TUBERCULOSIS  21/ 

Primary  and  Secondary  Tuberculosis. — A  pertisal  of  the  literature 
bearing  upon  tuberculosis  demonstrates  conclusixely  that  intestinal 
ttiberculosis  may  have  its  origin  either  primarily  or  secondarily  in 
the  bowel,  but  there  is  still  a  wide  divergence  of  opinion  as  to  the 
relative  frecjuency  of  these  types  of  infection,  and  comprehensive 
statistics  ha\e  been  brotight  forward  by  authorities  to  corroborate 
iheir  respective  claims.  Even  so  great  an  authority  as  Koch  made 
the  statement  shortly  before  his  death  that  he  had  observed  but  few- 
cases  of  primary  infection.  An  anahsis  of  the  figures  indicates  con- 
clusiveh-  that  in  a  large  percentage  of  cases  bowel  tuberculosis  is 
secondary  to  the  disease  in  other  parts,  especially  the  lungs;  that 
primary  infection  occurs  more  frequently  than  is  supposed,  and  when 
present  is  usually  caused  by  the  bovine  bacillus  (typus  bovinus) 
which  has  gained  access  to  the  alimentar\-  tract  through  contaminated 
milk  or  food. 

To  show  the  frequent  association  of  intestinal  tuberculosis  with 
the  disease  elsewhere  in  adults  and  children,  and  the  relative  frequency 
of  primary  and  secondary  infections,  the  author  has  collected  and  tabu- 
lated the  following  statistics. 

Pertik's  Statistics. — Primary  intestinal  tuberculosis  is  calculated  by 
Zahn^  at  2.27  per  cent.  Grosser-  found  only  a  single  case  among  1407 
autopsies.  Secondary  intestinal  tuberculosis,  in  the  origin  of  which 
the  condition  of  the  stomach  is  evidently  an  important  factor,  was 
met  with  in  63;  21  per  cent,  of  all  cases  of  pulmonary  tuberculosis, 
according  to  Zahn,  and  in  47  per  cent.,  according  to  Grosser. 

AUTHOR'S    TABLE    SHOWING    FREQUENCY    OF    PRHLARY    INTESTINAL 

TUBERCULOSIS 


Name. 

Number  of  cases. 

Percentage  of  primary  in- 
testinal tuberculosis. 

Bicdert 

Harbitz   (collected   from   English 

sources) 

Ipsen 

Orth 

Eisenhardt. .          

3,104  (tuberculous  patients) 

1,458 

Number  not  stated 

44  (intestinal  tuberculosis) 
1.000 

Number  not  stated 
13,203  (general  autopsies) 
208  (intestinal  tuberculosis) 
769  (tuberculous  autopsies) 

369  (intestinal  tuberculosis) 

236 

128 

748 

963  (tuberculous  autopsies) 

410              "                " 

27  (intestinal  tuberculosis) 

58 

0.5  (children) 

19.0           " 
17.0 

10. 0           " 
0.1 

Zahn  (Osier) 

Ciechanowski  (Osier) 

2.27 
1.04 

Frerichs 

0.5 

Bonome 

Bovaird : 

American  autopsies 

German  autopsies 

French  autoj)sies 

English  autopsies 

Baginsky 

Wagner 

Eisenbach 

Herxheimer 

16.4 

1-33 
0.4 

18.0 

4.88 
29.6 
1.8 

Total 

22,725                                                       7-22 

1  MUnch.  Med.  Wochschrft.,  No.  2,  1902.      -  Inaugural  Dissertation,  Tubingen,  1900. 


2l8     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 


The  author's  comprehensive  study  of  the  subject  and  personal 
experience  with  intestinal  tuberculosis  warrants  the  statement  that 
the  disease  is  primary  in  less  than  lo  per  cent,  of  the  cases,  and  when 
it  is,  the  lesions  usually  originate  in  the  anorectal  region. 

To  show  the  apparent  correlation  between  diphtheria  and  intestinal 
tuberculosis,  and  determine  the  proportion  of  primary  infections  in 
these  cases,  Osier  collected  the  statistics  of  Heller,  Councilman,  Mal- 
lory,  Pearce,  and  Baginsky  as  follows,  which,  when  carefully  studied, 
throws  considerable  light  upon  an  obscure  feature  of  tuberculosis: 


Heller . . 

Councilman,  ISIallory,  Pearce 
Baginsky 


Deaths  from 
diphtheria. 


714 
220 
806 


General  and 
other  tuber- 
culosis. 


140 
35 

144 


Intestinal  tuber- 
culosis. 


53 

13 

6 


Primary  intestinal 
tuberculosis. 


7.4  per  cent. 

5-9 

0.7         " 


An  analysis  of  these  figures  indicates  that  intestinal  and  general 
tuberculosis  are  predisposing  causes  of  diphtheria. 

Many  theories  have  been  advanced  to  explain  why  the  disease 
attacks  the  cecum  so  very  much  more  frequently  than  other  parts  of 
the  intestine.  A  study  of  the  statistics  already  given  show  conclusively 
that  the  cecum,  the  lower  extremity  of  the  ileum,  and  beginning  of  the 
ascending  colon  are  the  seat  of  the  disease  in  85  per  cent,  or  a  larger  pro- 
portion of  all  cases  of  intestinal  tubercular  infections,  and  for  this  reason 
tuberculosis  of  the  ileocecal  region  deserves  separate  consideration. 

It  is  conceded  that  tubercle  bacilli  are  able  to  pass  through  the 
stomach  and  infect  the  bowel,  but  it  is  difficult  to  understand  why  it 
is  that  the  duodenum,  jejunum,  and  upper  ileum,  with  which  they  first 
come  in  contact,  escape,  while  the  cecum  is  so  frequently  attacked. 
There  are  many  reasons  which  can  be  advanced  which  would  help  to 
explain  the  predilection  of  tuberculosis  for  the  cecum  and  adjacent 
ileum  and  colon,  viz.: 

(i)  Because  the  fluidity  of  the  feces  and  more  pronounced  peris- 
talsis in  the  small  intestine  hurry  the  tubercle  bacilli  through  the 
upper  segments  of  the  small  bowel  so  quickly  that  they  have  no  oppor- 
tunity to  cause  infection. 

(2)  The  gastric  juice  attenuates  the  bacilli,  and  they  do  not  recover 
sufificiently  to  set  up  a  tubercular  process  until  they  have  reached  the 
cecum  or  colon,  where  they  arc  retained  long  enough  for  them  to  regain 
their  vitality  and  find  a  lodging-place. 

(3)  In  the  ileocecal  region  the  feces  have  a  strong  alkaline  reaction, 
while  higher  up  they  are  acid  owing  to  the  gastric  juice,  which  inhibits 
bacillary  activity. 

(4)  In  the  cecum  and  ascending  colon  the  feces  are  prone  to  collect 
and  form  large  putty-like  or  hardened  masses,  which  sometimes  trau- 
matize the  mucosa,  produce  catarrh,  erosions  or  ulcers,  and  a  mucous 
discharge,  conditions  which  favor  a  local  infection  by  tubercle  bacilli. 

(5)  The  abundant  lymphatic  distribution  here  favors  the  develop- 
ment of  tuberculosis  in  the  ileocecal  region. 


CHAPTER   XX 

TUBERCULAR  ENTERITIS,   COLITIS,   AND   ENTEROCOLITIS 
UNTESTINAL  TUBERCULOSIS  ,  DIARRHEA  IN    Continued) 

CLASSmCATION,   PATHOLOGY 

Classification. — It  is  not  so  easy  as  it  would  at  first  appear  to 
classify  tubercular  lesions  of  the  intestinal  tract  which  are  capable  of 
inciting  diarrhea,  because  there  are  several  types  each  of  which  pre- 
sents a  different  picture  when  encountered  in  its  various  stages,  and. 
further,  because  the  authorities  have  evidenth-  discussed  the  same 
forms  of  the  disease  under  ditterent  names. 

It  has  been  the  custom  of  the  author,  following  the  plan  of  Algla\"e. 
to  group  the  lesions  of  intestinal  tuberculosis  according  to  the  part  and 
manner  in  which  the  disease  attacks  the  intestinal  w'all,  lymph-nodes, 
and  peritoneum,  \\z.: 

(i)  Enteric  or  superficial  ulcerative  type. 

(2)  Enteroperitoneal  or  deep  ulcerative  type. 

(3)  Hyperplastic  (hypertrophic,  neoplastic). 

(4)  Fibrosclerotic. 

(5)  Glandular. 

(6)  Peritoneal. 

All  varieties  of  tuberculosis,  no  matter  whether  they  attack  the 
intestine  from  within  or  without,  produce  slight  or  persistent  diarrheal 
attacks  at  one  stage  or  another.  Enteric  occurs  far  more  frequently 
than  enteroperitoneal  tuberculosis,  which  is  encountered  more  often 
than  the  hyperplastic  (neoplastic)  form.  The  other  types  of  the 
disease  are   of  rare  occurrence. 

In  some  instances  two  varieties  may  be  present  in  independent 
parts  of  the  gut,  or  they  may  be  localized  in  a  single  segment,  under 
which  circumstances  it  is  difficult  to  diagnose  the  true  condition  by 
clinical  and  pathologic  findings. 

The  relative  frequency  with  which  the  dift'erent  types  occur  is  very 
well  shown  in  the  52  specimens  of  intestinal  tuberculosis  mentioned 
by  Alglave  and  tabulated  b\'  the  author. 


TABLE  OF  .52  SPECIMENS  OF  INTESTINAL  TUBERCULOSIS 

Varieties.                                          '        Number  of  cases. 

Percentage. 

Enteric 

Enteroperitoneal 

Hj'perplastic 

28 

14 

5 

4 

I 

53-9 

26.9 

9.6 

Peritoneal 

7-7 

Glandular 

1.9 

Total 

52 

219 


220     TUBERCULAR    ENTERITIS,    COLITIS.    ENTEROCOLITIS.    DIARRHEA    IN 

The  author  has  made  a  comprehensive  study  of  the  published 
statistics  upon  intestinal  tuberculosis,  and  from  this  analysis  and  his 
personal  experience  he  feels  justified  in  stating  that  the  enteric  or  super- 
ficial ulcerative  t\pe  prevails  in  about  80  per  cent,  of  the  cases.  He  is 
aware  that  the  peritoneum  is  involved  in  perhaps  20  per  cent,  of  the 
cases,  but  believes  that  in  many  instances  the  serosa  becomes  affected 
secondarily  from  extensions  of  the  tubercular  process  or  mixed  infec- 
tion, which  would  explain  the  frequency  with  which  the  peritoneal 
coat  is  obser\-ed  to  be  diseased  during  operations  or  at  autopsies  upon 
tubercular  subjects.  Again,  considerable  infiltration  may  take  place 
in  the  coats  of  the  intestine  in  enteric  tuberculosis,  and  because  of 
the  thickness  and  firmness  induced  in  the  gut  wall  the  process  is 
occasionalh"  mistaken  for  the  hyperplastic  variety,  or.  when  the  lymph- 
nodes  become  secondarily  involved,  for  the  glandular  t\pe  of  the 
disease. 

The  enteric  and  enteroperitoneal  forms,  like  hyperplastic  tuber- 
culosis of  the  gut,  are  comparatively  rare  in  the  upper  small  bowel 
and  colon,  although  they  are  found  considerably  more  frequently  than 
the  hyperplastic,  but  the  different  varieties  are  encountered  in  the 
ileocecal  region  in  about  85  per  cent,  of  all  cases. 

The  statistics  of  Hemmeter  and  other  authorities  upon  the  sub- 
ject show  that  there  is  an  enteritis  or  enterocolitis  (catarrhal  or  tuber- 
cular) in  practically  all  persons  who  die  of  tuberculosis  of  the  lungs  or 
other  organs.  If  this  is  so.  and  there  is  no  reason  to  believe  otherwise, 
intestinal  tuberculosis  is  not  only  secondan.-.  but  occurs  frequently. 

PATHOLOGY 

Enteric  (Superficial  Ulcerative  Type)  Tuherculosis.—V\cerQ.l\\e  is 
the  most  frequent  t\'pe  of  intestinal  tuberculosis,  and  when  present 
excites  a  persistent  diarrhea.  This  condition  is  usually  secondary-  to 
tubercular  lesions  in  the  lung  and  elsewhere.  It  is  met  with  in  all 
parts  of  the  intestinal  tract,  but  shows  a  predilection  for  the  lower 
ileum,  cecum,  ileocecal  valve,  and  ascending  colon  (Fig.  28).  regions 
bountifully  supplied  with  h-mphoid  tissue.  solitar\-  follicles,  and  Pey- 
er's  patches.  In  the  28  cases  of  enteric  tuberculosis  mentioned  in  the 
preceding  table  the  ileum  was  affected  exclusively  in  7,  in  20  the 
cecum  was  diseased  (3  times  exclusively),  while  in  12  cases  the  appen- 
dix was  involved  fonce  exclusively). 

In  specimens  examined  by  the  author  the  ulcerated  areas  were 
numerous  and  most  marked  opposite  the  mesenteric  attachment, 
indicating  involvement  of  Peyer's  patches,  though  in  places  the 
solitary  follicles  were  included  in  the  destructive  process. 

Formerly  it  was  thought  that  the  tubercular  foci  originated  in 
the  superficial  mucosa  independently  of  these  patches  and  glands,  but 
the  investigations  of  Orth  and  Baumgarten  have  conclusively  shown 
that  the  reverse  is  true,  and  that  the  disease  has  its  inception  in  these 
structures,  and  that  tubercle  bacilli  and  giant  cells  are  to  be  found 
both  in  the  closed  follicles  and  base  of  the  ulcers.     In  catarrhal,  tv- 


PATHOLOGY 


221 


phoid,  and  other  infections  the  entire  Peyer's  patch  is  affected,  but 
in  tul)erculosis  a  single  gland  or  se\'eral  indixidual  follicles  or  small 
aggregations  of  glands  within  the  patch  ma\'  he  attacked,  while  others 
remain  healthy.  Shortly  following  infection  the  solitary  glands  or 
part  of  Peyer's  patch  affected  become  more  prominent,  owing  to 
distention  of  the  follicles  with  tu- 
bercular tissue  and  bacillary  inflam- 
mation, and  later,  through  impair- 
ment to  nutrition  or  caseation, 
overlying  structures  give  way  and 
diminutive  lesions  form.  As  soon 
as  the  mucosa  become  ulcerated 
the  disease  progresses  rapidl\-  be- 
cause of  the  irritating  poisons  em- 
anating from  the  tubercular  foci, 
formation  and  subsequent  caseation 
of  new  tubercles,  mixed  infection 
and  necrosis  from  the  endarteritis, 
and  in  time  extensive  ulcerated 
areas  form  through  enlargement  of 
a  single  lesion  or  the  coalescing  of 
several  lesions. 

Some  authorities  believe  that 
extension  of  the  disease  is  due 
principally  to  the  successive  forma- 
tion and  caseation  of  the  tubercles, 
but  the  author  holds  with  Maylard 
that  when  the  destructive  process 
is  marked,  progression  is  principally 
due  to  mixed  infection  resulting 
from  the  tubercular  foci  and  low- 
ered resistance  of  the  patient,  for 
the  granulated  mucosa,  fecal  stasis, 
and  the  pathogenic  and  sapro- 
phytic micro-organisms  within  the 
bowel  all  favor  a  vsecondary  or 
mixed  infection.  While  in  many 
instances  pathogenic  cocci  predomi- 
nate in  the  lesions,  evidences  of  the 
tubercular  process  can  be  deter- 
mined by  careful  study.  In  fact, 
where    there    are    enormous    ulcers 

with  excavated  edges  or  the  mucosa  is  in  shreds  or  completely  destroyed 
over  an  area  of  several  inches  the  destruction  of  tissues  is  due  more  to 
the  mixed  than  to  the  original  or  tubercular  infection.  When  other 
micro-organisms  participate  actively  in  the  inflammatory  process  the 
mucosa  suffers  greatly  and  perforation  as  well  is  likely  to  take  place. 

1  Army  Med.  Museum. 


2&. — Tubercular    ulceration    (as- 
cending colon).' 


222     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

Enteric  tubercular  ulcers  rarely  penetrate  beNond  the  mucosa,  and, 
except  when  mixed  infection  is  a  complication,  they  show  a  tendency 
to  heal,  an  evidence  of  which  is  to  be  seen  in  the  scar  tissue  at  the 
base. 

In  some  instances  the  disease  extends  without  apparent  limita- 
tion, but  in  others  healing  takes  place  at  one  point  while  ulceration 
is  progressing  in  another. 

The  characteristics  of  tubercular  ulcers  of  the  intestine  are  fairly 
well  known.  These  lesions  are  usually  gray  in  color,  have  a  greasy 
appearance,  a  macerated  base  (composed  of  degenerated  and  caseat- 


Fig.  29. — Tubercular  ulcers  (ileum). 
(Lower  two  touched  up  to  look  like 
specimen.)' 


Fig.  30. — Perforating  intestinal  tuberculosis 
(adult  with  phthisis).' 


ing  tissue  and  fragments  of  mucosa),  their  edges  may  be  smooth  or 
irregular,  soft  or  indurated,  swollen  or  edematous,  undermined  (Fig. 
29)  or  bulging  (rarely),  and  tubercles  (often  in  a  state  of  caseation) 
are  frequently  to  be  seen  on  the  margins  or  near  the  lesions.  In  the 
enteric  form  of  intestinal  tuberculosis  the  ulcers  are  usually  super- 
ficial, but  may  extend  to  the  muscular  tunic,  or,  in  rare  instances, 
penetrate  the  bowel  (Fig.  30)  and  cause  peritonitis  or  abscess. 
They  vary  in  shape  and  may  be  circular,  elongated,  or  irregular; 
single  or  several  lesions  may  coalesce.  Usually,  however,  the  ulcers 
take  the  direction  of  the  vessels  and  extend  transversely  to  the  long 

1  Army  Med.  Museum. 


PATHOLOGY  223 

axis  of  the  bowel,  until  they  partially  or  completely  encircle  it,  from 
whence  they  derive  the  name  of  ^^irdle  ulcers  (Figs.  29,  31).  On  account 
of  ensuing  infiltration,  the  cicatrices  formed  when  the  ulcers  heal,  or 
enterospasm  consequent  upon  the  irritation  of  the  terminal  nerve  fila- 
ments, the  bowel  may  be  obstructed  to  a  varying  degree.  Enteric 
tubercular  ulcers  show  less  tendency  to  heal  than  those  caused  by 
catarrhal  and  other  forms  of  ulcerative  colitis. 

Enteric  is  sometimes  described  as  granulating  tubercuUjsis.  be- 
cause of  the  uneven  surface  of  the  mucosa  produced  by  the  promi- 
nence of  the  distended  solitary  glands  and  une\en  surface  (A  the 
mucosa  after  they  have  broken  down. 

The  peritoneum  shows  evidences  of  the  tubercular  i)r(K('s>  in  all 
varieties  of  the  disease  independent  1\  and  when  perforation  lias 
taken  place.  Sometimes,  e\en  in  the  mild  cases  of  enteric  tubercu- 
losis, dark  spots  are  to  be  seen  ui)on  the  peritoneum  over  the  base  of 
ulcers;  the  serosa  is  slightly  swollen  and  presents  an  uneven  surface 
(Figs.  32,  33).  When  ulcers  penetrate  deeply  into  the  intestinal  wall, 
exudates  are  thrown  out  and  the  serosa  becomes  agglutinated  to  ad- 
jacent organs  or  structures  and  loops  of  intestine,  and,  in  the  presence 
of  a  perforation,  local  or  general  peritonitis  ensues,  which  is  often  com- 
plicated by  a  pyostercoral  fistula.  The  intestinal  wall  varies  in  the 
ulcerative  tubercular  colitis,  and  may  be  thickened  by  the  exudates, 
thinned  through  the  destructive  processes,  and.  in  either  case,  it  may 
be  resistant  or  fragile. 

Usually  only  diminutive  vessels  are  eroded,  but  occasionalh'  larger 
arterioles  are  involved  b\-  the  lesions,  in  which  case  profuse  hemor- 
rhages occur. 

Enteroperitoneal  {Deep  Ulcerative)  Tuberculosis. — The  author  re- 
gards enteroperitoneal  (Fig.  31)  as  the  most  dangerous  type  of  intes- 
tinal tuberculosis,  because  the  destructive  process  progresses  rapidly,  is 
ver>-  extensive,  always  difficult  and  frequently  impossible  to  arrest,  and 
terminates  fatally  more  often  than  other  forms  of  the  disease.  It  is 
serious  because  tubercular  foci  are  present  sooner  or  later  in  both  the 
mucous  membrane  and  serosa,  and  frequently  the  process  starts  simul- 
taneously (hematogenously )  in  both.  Again,  in  enteroperitoneal  tuber- 
culosis caseation  takes  place  early  because  of  the  virulence  of  the  infec- 
tion and  activity  of  other  pathogenic  organisms,  and  the  lesions  result- 
ing therefrom  rapidly  extend  to  and  involve  all  the  bowel  tunics  and 
bring  about  serious  complications,  viz.:  constitutional  manifestations, 
extensive  ulceration,  formation  of  scar-tissue  and  stenosis,  toxemia, 
hemorrhages,  papillomatous  excrescences,  and  often  jiertoration. 
adhesions,  peritonitis,  abscess,  and  pyostercoral  fistula,  which  find 
an  outlet  through  neighboring  organs  or  the  abdominal  wall,  and 
with  stricture  where  the  patient  recovers. 

Ver>'  often  the  pathogenic  bacteria  which  normalK  inhabit  the 
bowel  are  active  in  these  cases,  and  the  destruction  of  tissue  which 
follows  is  due  more  to  them  than  the  caseation  of  tubercles.  When 
mixed  infection  is  pronounced,  destruction  of  the  tissue  ensues,  and 


224     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

often  the  mucosa  is  destroyed  o\'er  considerable  areas  or  is  ragged 
and  marked  by  deep  excavated  ulcers.     Here,  as  in  other  tubercular 


Fig.  31.— Extenjiive  enteroperitoneal  tubercular  lesions  (ileum).     Left:  Mucosa.     Right: 

Peritoneal  surface.' 

ulcerative  processes,  the  lesions  most  frequently  take  a  direction  at 
right  angles  to  the  long  axis  of  the  bowel. 

'  Army  IMed.  JMuseum. 


patholo(;y 


225 


A  study  of  the  author's  personal  together  with  i)ul)Hshe(l  eases 
indicates  that  the  tubercular  process  usually  originates  in  the  mucosa 
and  rapidly  extends  outward  and  involves  the  entire  gut  wall  (Fig. 
32)  and  mesenteric  glands  by  contiguity,  or  through  lymph-channels, 
while  in  a  few  instances  it  starts  in  neighboring  glands  or  the  [)eri- 
toneuni  and  works  inward  or  attacks  the  gut  intrinsically  and  ex- 
trinsically  at  the  same  time,  under  which  circumstances  all  the  coats 
become  involved  with  great  rapidity,  it  is  encountered  with  regular- 
ity in  the  lower  ileum,  the  cecum,  ascending  colon,  and  appendix,  is 
not  so  frequently  localized  as  the  enteric  type,  but  more  often  con- 


M 

^\^^'i\       ^ 

'»'■ 

■- 

-  ^^'--  i^  *■    i^ 

') 

;■.  .vS;.^  \     ■  *^ 

1 

\^ 

.^V     .  f 

i 

'\  ..   >.  ..  ■ 

1 

'.-.  A-,<i,-vi-  '  • 

1 

•   -,v-                 ^»^>- 

« 

•:r3^:'at^  ^%<. 

,'■' 

"" 

1              /     ^. 

'  ^   >,. 

'      '• 

, 

■^./  ■    -" ..  "v.: 

■  \ .     "^ ' ;-    - 

•  L  • 

.  -           ■    \ 

[ 

i 

-  ^..     --C    V    c     - 

'.  1 

V. :       V  ■    ,  ■  N- 

•\ 

; 

\  t'^ '. 

■-.:  ^.'- -^  ^ 

1 

V 

, 

^  ^             ,     ^    . 

'  T 

1 

^>\+-'^'    -V:     ;    . 

-^ 

\ 

•        V     "     ^      • 

t 

>^ 

y 

i 

Fig.  7,2. — Enteropcriloncal   tubc-nular  uIllts  and  niiliaiv  tlciK),-.ll.>  (ileum).     Left:  Peri- 
toneal surface.     Right :  Mucosal 


tinuously  involves  several  feet  of  the  small  and  large  intestine,  though 
in  some  cases  there  may  be  intervening  areas  of  healthy  guts 

The  author  has  observed  but  3  cases  where  the  process  appeared 
to  be  confined  to  segments  of  the  small  bowel,  and  in  these  it  was  more 
pronounced  in  the  lower  ileum.  The  ileocecal  region  is  usually  dis- 
eased, and  foci  may  extend  either  to  the  ileum  or  lower  colonic  segments 
and  rectum. 

Because  of  peritoneal  invc^hement  and  amount  ot  infiltrates 
thrown  out,  the  gut  becomes  glued  to  the  appendix,  coils  of  the  small 
bowel,  other  organs,  or  parietes  in   the  early  stages  of  the  disease, 

'  Army  ISIed.  Museum. 


226     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

\vhich  interferes  with  peristalsis,  incites  enterospasm,  obstipation,  or 
alternating  diarrhea  and  constipation. 

The  mesenteric  glands  are  enlarged  through  inflammatory  changes 
or,  more  often,  tubercular  foci.  The  tubercular  process  may  be  arrested 
by  calcification  or  the  nodes  may  be  partially  or  completely  destroyed 
through  caseation  and  suppuration,  the  discharge  from  which  finds 
its  way  to  the  agglutinated  bowel  or  abdominal  covering  to  cause 
peritonitis  or  abscess. 

Perforation  occurs  in  only  6  to  8  per  cent,  of  the  cases  of  the  enteric 
variety  because  the  process  is  often  arrested  at  the  muscular  tunic,  but 
takes  place  more  often  in  the  enteroperitoneal  type,  owing  to  the  fact 
that  all  of  the  intestinal  coats  are  involved.  The  bowel  in  these 
forms  of  the  disease  has  no  fibrosclerotic  covering  like  the  neoplastic 
type  to  protect  the  abdominal  cavity  from  infection  in  case  of  per- 
foration, but  the  gut  is  usually  encompassed  by  adhesions  and  infil- 
trates sufficiently  to  limit  the  infective  process  and  prevent  peritonitis. 
The  barriers  act  as  a  shield  against  the  formation  of  abscesses  in  the 
majority  of  instances,  but  are  not  sufficiently  strong  to  restrain  the  pus 
and  feces  at  all  times.  Consequently,  abdominal  pyostercoral  fistulae 
are  encountered  in  this  far  more  frequently  than  the  other  types  of 
intestinal  tuberculosis.  In  the  anorectal  region  this  form  of  tubercu- 
losis is  a  frequent  cause  of  abscesses  and  fistula?,  because  there  are 
neither  a  peritoneum  nor  adhesions  to  protect  the  perirectal  tissues  and 
limit  the  suppurating  process. 

Intrinsicalh',  enteroperitoneal  tuberculosis  extends  in  the  same 
way  and  has  the  same  characteristics  as  the  enteric  type,  with  the 
exception  that  the  ulcers  rarely  cicatrize  and  form  stenoses,  but  may 
lead  to  more  or  less  obstruction  through  the  presence  of  complicating 
large  or  small  papillomatous  or  polypoid  growths  which  macroscopic- 
ally  and  microscopically  resemble  benign  adenomata. 

Usually  in  this  form  of  the  disease  miliary  tubercles  are  to  be  seen 
in  patches  scattered  throughout  the  peritoneal  covering  of  the  in- 
volved gut  (Fig.  32),  some  as  smooth  nodules  and  others  as  excoriated 
diminutive  swellings  when  caseation  has  taken  place.  The  serosa  is 
always  highly  congested,  and  all  of  the  bowel  tunics  are  extremely 
fragile  and  readily  tear  when  the  slightest  tension  is  made  upon  the 
gut  or  an  attempt  is  made  to  separate  one  intestinal  coil  from  another. 
In  this  class  of  cases  the  gut  has  a  doughy  feel  and  ulcers  are  not  as 
readily  discernible  from  without  as  in  the  enteric  form,  owing  to  the 
thickened  condition  of  the  bowel.  In  both  types  of  the  disease  casea- 
tion may  take  place  and  minute  intermural  abscesses  may  form  which 
open  through  the  peritoneum  into  the  gut  lumen. 

Finally,  enteroperitoneal  tuberculosis  more  rapidly  goes  to  a  fatal 
termination  through  exhaustion  of  the  patient  or  other  complications, 
because  there  is  but  little  tendency  on  the  part  of  the  tubercles  to 
undergo  calcification  or  of  the  ulcers  to  cicatrize.  In  other  respects 
the  changes  which  take  place  in  the  enteroperitoneal  are  similar  to 
those  of  the  ulcerative  enteric  type  and  require  no  further  elucidation. 


HYPERPLASTIC    (HYPERTROPHIC    NEOPLASTIC)    TUBERCULOSIS      227 

Hyperplastic  (Hypertrophic  Neoplastic )  Tuberculosis. —  History 
and  General  Remarks. — Cecal  (hyperplastic)  tuberculosis  as  an  entity 
was  but  little  known  until  the  present  decade,  and  comparatively 
nothing  is  to  be  found  in  text-books  on  medicine  and  surgery  con- 
cerning it.  The  current  literature  prior  to  1890  contained  but  a  few^ 
scattered  articles  upon  this  interesting  condition,  but  in  the  last  few 
years  several  valuable  contributions  have  been  made  to  the  subject, 
so  that  at  present  the  etiology,  pathology,  symptoms,  diagnosis,  and 
treatment  of  ileocecal  neoplastic  tuberculosis  is  fairly  well  understood. 

The  excellent  contribution  of  Hartmann  and  Pilliet  (1891)  served 
to  excite  great  interest  in  this  subject,  and  their  publicatifMi  was 
followed  shortly  afterward  by  other  articles  along  similar  lines.  It 
remained  for  Coquet  (1894)  to  call  attention  to  and  apply  the  term  of 
hyperplastic  to  a  frequent  type  of  cecal  tuberculosis  associated  with 
tumor  formation.  Among  those  who  have  done  most  to  increase  our 
knowledge  concerning  ileocecal  neoplastic  tuberculosis  the  names  of 
Durante,  Alglave,  Tissier,  Tiery,  Eisenhardt,  Conrath,  Crowder, 
Epstein,  Mayo  Robson,  Keetley,  Kidd,  Fenw'ick  and  DodwcU, 
Lartigan,  Campiche,  Wagner,  and  Cumston  stand  out  most  promi- 
nently. 

Hyperplastic,  from  a  surgical  standpoint,  constitutes  the  most 
interesting  type  of  tuberculosis,  because  here,  as  the  result  of  infection, 
a  tubercular  mass  forms  which  may  attain  considerable  dimensions, 
yet  it  is  one  which  can  be  removed  with  comparati\'ely  little  danger 
and  generally  with  the  assurance  that  the  patient  will  be  cured. 
Because  of  their  size  and  dense  character  these  neoplasms  have  often 
been  mistaken  for  fecal  impactions,  malignant  growths,  and  other 
tumor  formations,  and  have  been  designated  as  pseudoneoplasms  and 
neoplastic  tubercular  tumors. 

The  author  has  treated  two  patients  afflicted  w^ith  this  condition 
wherein  a  mistaken  diagnosis  of  carcinoma  was  made  by  himself  and 
other  diagnosticians,  and  the  true  condition  was  not  discovered 
until  operation.  The  first  case  was  that  of  an  old  man  who  had  been 
sick  for  months,  was  emaciated,  and  suffered  from  chronic  obstruction, 
but  whose  case  presented  several  features  not  characteristic  of  a  can- 
cerous process,  and  where  at  operation  the  non-malignancy  of  the 
trouble  was  confirmed  by  the  picture  presented  and  the  examination  of 
a  section  of  the  tumor.  In  the  second  case  the  tumor  was  assumed  to 
be  cancer  by  one  physician  and  a  fecal  impaction  incident  to  stricture 
by  another,  but  the  author  held  otherwise,  on  account  of  the  patient's 
age  (thirty  years),  the  chronicity  of  the  disease  and  unusual  history, 
and  advised  an  exploratory  examination,  which  revealed  the  tubercular 
nature  of  the  tumor. 

Age  appears  to  have  a  predisposing  influence  in  the  production 
of  neoplastic  tuberculosis,  and  individuals  ix'tween  the  ages  of  twenty 
and  forty  (those  most  acti\ely  engaged  in  life's  w^ork)  are  most  fre- 
quently afflicted.  This  affection  has  been  encountered  in  young 
children  and  the  aged,  but  it  occurs  most  often  in  the  third  decade. 


228     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

Guinon  and  Pater  have  recorded  a  case,  that  of  a  girl  of  four  years, 
who  suffered  from  this  condition,  and  the  author  has  operated  for 
the  reUef  of  a  large  neoplastic  tumor  involving  the  cecum  in  a  man 
sixty-eight  years  of  age. 

In  Hofmeister's  series  (35  cases)  there  were  18  women  and  17 
men,  and  in  Hartmann's  219  operated  cases  there  were  112  females 
and  107  males. 

Neoplastic  tuberculosis  has  been  detected  in  different  segments 
of  the  small  and  large  intestine,  but  shows  a  decided  predilection  for 
the  cecal  and  ileocecal  regions.  In  fact,  it  diminishes  rapidly  in  fre- 
quency the  further  one  gets  away  from  the  cecum,  both  as  regards  the 
small  and  large  bowel,  but  it  has  been  encountered  in  the  rectum 
fairly  often. 

The  appended  table  shows  the  distribution  of  the  neoplasm  in  the 
100  cases  collected  by  Mummery: 

Sigmoid  flexure 6 

Cecum 48 

Cecum  and  ascending  colon 39 

Whole  colon 4 

Cecum,  ascending  and  transverse  colon 3 

Total 100 

Conrath  holds  that  the  cecum  is  the  seat  of  the  disease  in  85  per 
cent,  of  all  intestinal  tubercular  infections,  and  the  statistics  of  Hof- 
meister  (91  cases)  show  that  in  60  per  cent,  there  was  ileocecal  involve- 
ment. To  emphasize  the  frequency  and  surgical  importance  of  ileo- 
cecal hyperplastic  tuberculosis  it  is  only  necessary  to  mention  that 
Hartmann,  as  far  back  as  1906,  collected  219  cases  operated  upon  for 
the  relief  of  this  condition,  and  that  current  literature  demonstrates 
that  this  affection  is  being  diagnosed  and  treated  very  much  more 
often  now  than  formerly. 

Hyperplastic  occurs  less  frequently  than  either  enteric  or  entero- 
peritoneal  types,  as  is  shown  by  Bernay's  statistics  of  tubercular  intes- 
tinal stricture,  where  the  stenosis  was  induced  by  this  condition  in  but 
8  out  of  70  cases. 

Neoplastic  is  usually  independent  of  the  other  forms  of  tuberculosis, 
but  instances  have  been  recorded  where  it  and  the  enteric  or  entero- 
peritoneal  form  of  the  disease  were  found  in  the  same  and  different 
segments  of  the  gut. 

Hyperplastic  tuberculosis  may  involve  a  single  segment  of  the 
small  intestine  alone,  but  is  usually  concomitant  with  ileocecal  tuber- 
culosis, and  takes  its  origin  at  or  in  close  proximity  to  the  ileocecal 
valve,  when  the  swelling  may  be  felt  in  the  small  gut.  but  the 
enlargement  is  smaller  and  less  resistant  than  neoplastic  tubercular 
growths  of  the  cecum,  colon,  or  rectum. 

Neoplastic  tubercular  tumors  are  usually  single,  but  may  be  mul- 
tiple, with  sometimes  healthy  gut  intervening,  as  occurred  in  the 
cases  of  Trendelenburg,  where  there  were  five,  and  of  Borsch,  where 
there  were  four,  enlargements;  or  extensive  segments  of  the  bowel 


HYPERPLASTIC    (HYPERTROPHIC    NEOPLASTIC)    TUBERCULOSIS      229 

may  undergo  hyperplastic  degeneration  and  leave  the  gut  rigid  and 
tube-like  {gas- pipe  intestine),  similar  to  the  cases  reporetp  by  Lartigau 
and  others.  The  writer  possesses  a  specimen  of  a  woman  thirty-five 
years  of  age  who  suffered  from  chronic  obstruction  of  this  type,  where 
the  rectum  and  sigmoid  Hexure  had  completely  undergone  fibrosis  and 
nothing  short  of  excision  relieved  her. 

Hyperplastic  tuberculosis  differs  from  other  types  of  tuberculosis 
in  that  it  is  chronic,  and  the  disease  progresses  so  slowly  that  danger- 
ous manifestations  may  not  appear  for  many  months  or  years.  It 
has  been  observed  where  this  type  of  intestinal  tuberculosis  is  as- 
sociated wiih  tubt-rcular  infection  elsewhere  that  the  latter  is  always 
less  actix'e  than  when  it  is  a  complication  of  the  enteric  or  enteroperi- 
toneal  types.  From  what  has  been  said  it  may  be  inferred  that  a 
person  suffering  from  neoplastic  tuberculosis,  alone  or  concomitant 
with  the  disease  elsewhere,  has  a  greater  resistance  and  lives  longer 
than  individuals  under  similar  circumstances  who  are  afflicted  with 
the  more  virulent  forms  of  bowel  tuberculosis.  This  power  of  resist- 
ance stands  the  patient  well  in  case  of  operation,  and  recovery  is 
quicker  and  more  apt  to  be  permanent  following  surgical  intervention 
for  the  relief  of  neoplastic  than  other  types  of  intestinal  tuberculosis. 

Neoplastic,  like  other  tubercular  processes,  may  be  primary  or 
secondary,  and  some  contend  that  the  disease  is  always  primary. 
Certainh-,  statistics  concerning  tubercular  lesions  of  the  intestine 
prove  that  the  hyperplastic  form  is  secondary  to  involvement  of  the 
lungs,  bowel,  or  other  organs  very  much  less  often  than  either  the 
enteric  or  enteroperitoneal  types. 

The  following  statistics  of  Mummery  indicate  the  infrequency  with 
which  hyperplastic  tuberculosis  of  the  intestine  is  associated  with 
tubercular  disease  elsewhere,  viz.: 

No  other  tuberculous  lesion 76 

Tuberculous  cavaty  in  lungs  or  scars  of  old  phthisis 18 

Tuberculous  peritonitis i 

Tubercle  of  tibia i 

Tubercle  of  genito-urinary  tract 2 

Tubercle  of  phalanges i 

Tuberculous  ulcer  in  vagina ; i 

Total 100 

Hyperplastic  tuberculosis  of  the  intestine  may  be  caused  b>-  human 
or  bovine  bacilli,  and  the  infection  may  be  direct  (from  milk  and  food) 
or  secondary  to  the  disease  in  the  lungs.  In  the  body,  bovine  (typus 
bovinus)  are  less  active  than  human  tubercle  bacilli,  and  because  of 
this  and  the  fact  that  the  hyperplastic  is  more  chronic  than  other  forms 
of  tuberculosis,  and  the  frequency  with  which  these  l^acilli  are  swal- 
lowed in  milk,  cream,  butter,  cheese,  and  meat,  it  is  not  unreasonable 
to  assume  that  primary  infection  is  fairly  common  and  induced  by 
bovine  bacilli;  but  when  neoplastic  tuberculosis  is  secondars'  to  lung 
involvement  it  is  probably  caused  by  human  tubercle  bacilli. 

Hyperplastic  (neoplastic)  tubercular  swellings  are  usually  present 


230     TUBERCL'LAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 


as  sharply  defined,  fixed  or  slightly  movable,  firm,  smooth,  oval,  or 
irregular  tumor  formations.  Usually  the  hypertrophic  process  in- 
volves the  entire  circumference  of  the  cecum  uniformly,  but  occa- 
sionally the  infiltration  is  more  marked  and  the  cecal  wall  thicker  pos- 
teriorly. In  a  few  instances  the  disease  has  been  limited  to  the  side 
of  the  bowel,  producing  an  inward  projection  which  caused  obstruc- 
tion and  a  similar  enlargement  externally.  In  the  vast  majority  of 
cases  the  infiltration  involves  all  the  tunics  of  the  gut  (Fig.  33),  but 
in  a  few  necropsies  it  has  been  limited   to  one  or  more  coats,  under 


Fig.  ^^. — Left:  Tubercular  ulceration  and  tumor   of  cecum.     Right:   Tubercular  tumor 

of  peritoneum.' 

which  circumstances  the  infiltrates  are  located  principally  in  the  sub- 
serosa  and  submucosa.  The  enlarged  cecum,  including  a  part  of  the 
ileum  and  ascending  colon  w'hen  involved,  are  not  entirely  responsible 
for  the  large  size  of  these  tumors,  since  they  are  in\'ariably  encapsu- 
lated by  a  fibro-adipose  sheath,  varying  in  thickness  from  f  to  Ij  in. 
(2-4  cm.),  which,  together  with  surrounding  adhesions,  help  to  make 
up  the  swelling.  This  pseudocapsule  can  be  separated  from  the 
enlarged  bowel  by  careful  dissection  during  operation  or  autopsy. 
In  exceptional  cases  where  the  neoplasm  is  of  very  considerable  size 

^Army  Med.  Museum. 


HYPERPLASTIC    (HYPERTROPHIC    NEOPLASTIC)    TUBERCULOSIS      23 1 

the  mass  is  made  up  of  the  hyperplastic  cecum,  its  capsule,  appendix, 
adhesions,  intestinal  coils,  and  enlarged  lymph-nodes  glued  together. 
The  cecum  is  usually  adherent  laterally  and  posteriorly,  but  is  rarely 
attached  to  the  anterior  abdominal  wall  by  the  adhesions. 

The  covering  resembles  that  found  about  tubercular  kidneys,  and 
is  made  up  largely  of  normal  adipose  tissue  and  fat  which  has  under- 
gone fibrous  changes.  In  the  author's  case,  where  perforation  had 
taken  place  and  a  pericecal  abscess  was  discovered,  the  fibrous  cap- 
sule had  evidently  limited  the  infection  and  prevented  general  peri- 
tonitis. 

Upon  section,  hyperplastic  tuljercular  tumors  are  resistant  to  the 
knife,  grayish-white  in  color,  and  resemble  cartilage,  owing  to  the 
presence  of  an  abundance  of  fibrous  tissue.  The  gut  wall  varies  in 
thickness  from  ^  to  i  inch  (1-3  cm.)  or  more,  a  condition  which  ex- 
plains the  size  of  the  swelling  and  manifestations  of  obstruction. 
In  the  earlier  stages  the  lumen  may  be  but  slightly  occluded,  but  later 
it  is  often  almost  or  quite  obliterated,  specimens  having  been  examined 
where  it  was  difficult  or  impossible  to  introduce  a  probe  through  the 
stenosis.  In  these  cases  the  gut  is  rigid,  non-collapsible,  and  the 
blocking  results  from  the  infiltration  and  thickening  of  the  intestinal 
tunics,  and  not  from  the  contraction  of  cicatricial  tissue,  as  occurs  in 
ulcerative  intestinal  tuberculosis.  The  stricture  may  be  annular  or 
tubular,  the  inner  surface  being  smooth  when  the  mucosa  is  intact,  or 
irregular  when  ulcers  or  papillomatous  growths  are  present,  and  the 
gut  proximal  to  the  stenosis  is  often  dilated.  The  obstruction  is  not 
always  produced  solely  by  hyperplasia,  as  there  may  be  a  concomitant 
tubercular  enteritis  or  colitis,  which  results  in  the  formation  of  cica- 
tricial tissue,  and  that,  in  turn,  helps  to  diminish  the  lumen  of  the  gut 
through  contraction. 

In  exceptional  instances  the  smooth  cartilaginous  appearance  of 
the  thickened  intestinal  wall  may  show  a  cavity  the  result  of  casea- 
tion, under  which  circumstances  the  bowel  has  less  resistance  w^ien 
compressed  between  the  fingers. 

In  this  class  of  cases  the  ensuing  stricture  never  presents  as  a 
crescentic  fold  or  membranous  partition.  Through  the  formation  of 
hyperplastic  tissue  and  shortening  which  follows,  the  cecum  and 
ascending  colon  are  frequently  displaced  upward.  The  circulation  is 
considerably  impaired  in  these  neoplastic  swellings,  but  occasionally 
one  portion  is  found  quite  vascular. 

The  mucous  membrane  in  hyperplastic  tuberculosis  may  remain 
intact,  but  more  often  it  is  involved  in  the  tubercular  process,  and  by 
mixed  infection,  fecal  impaction,  or  other  non-tubercular  types  of 
colitis  is  inflamed,  eroded,  or  ulcerated.  Because  the  continuity  of  the 
mucous  membrane  is  occasionally  broken  some  authorities  contend 
that  fibrosis  in  these  cases  is  secondary  to  the  ulcerative  process,  but 
this  view  is  refuted  by  the  fact  that  many  cases  of  neoplastic  tuber- 
culosis have  been  reported  wherein  the  mucosa  remained  normal  and 
presented  no  evidences  of  scar-tissue.      Sometimes  both   the  h\-ix>r- 


22i2      TUBERCULAR    ENTERITIS.    COLITIS.    ENTEROCOLITIS,    DIARRHEA    IN 

plastic  and  ulcerative  t\'pes  of  tuberculosis  are  present  in  the  same 
case,  under  which  circumstances  the  fibrous  change  in  the  gut  is  attrib- 
uted to  both.  In  this  affection  the  mucosa  is  usually  thrown  into 
transverse  folds  through  atrophy  of  the  submucosa.  and  is  considerably 
thickened  owing  to  the  tubercular  colitis.  Tubercles  are  occasion- 
ally to  be  seen  and  may  undergo  caseation,  but  in  aggravated  cases, 
where  considerable  sized  areas  of  the  mucous  membrane  slough,  it  is 
due  to  impairment  of  its  circulation  or  breaking  down  of  tubercular 
foci  in  or  beneath  it.  When  there  are  a  number  of  such  large  ulcers 
the  surface  of  the  mucosa  may  be  mammillated  or  the  membrane 
may  be  undermined. 

The  most  characteristic  feature  of  hypertrophic  tuberculosis  is 
the  presence  of  numerous  polypoid  or  papillomatous  growths  having 
pedunculated  or  sessile  attachments  which  project  into  the  gut  lumen. 
These  excrescences  var\-  in  number,  size,  and  shape,  but  are  usually 
from  birdshot  to  hazel-nut  size,  clubbed  at  their  extremities,  and  are 
sometimes  seen  projecting  from  either  side  through  the  ileocecal  valve. 
In  one  case  they  may  be  isolated  and  few  in  number,  or  in  another 
numerous  and  segregated.  They  are  not  of  tubercular,  but  inflamma- 
tory- origin,  although  caseating  foci  have,  in  rare  instances,  been  found 
in  them.  They  originate  in  the  submucosa  and  consist  mainly  of 
connective-tissue  and  round-cell  infiltration,  and  have  an  epithelial 
covering  similar  to  that  of  the  mucosa.  Lartigau  and  others  found 
neither  tubercles,  necrosis,  nor  giant  cells  within  them,  but  tubercles 
have  been  observed  upon  their  mucous  covering  and  elsewhere. 

When  the  mucosa  is  involved  in  the  tubular  process,  tubercles 
containing  giant  and  an  abundance  of  round  cells,  and  sometimes 
necrotic  or  caseating  areas,  are  observed,  but  in  simple  catarrhal 
inflammation  only  round-celled  infiltration  is  discernible. 

Hyperplastic  tuberculosis  originates  in  or  attacks  the  suhmucosa 
early.  The  process  is  more  active  here  and  in  the  subserosa  than 
elsewhere,  and.  as  a  result,  active  round-celled  infiltration  ensues 
and  the  submucosa  becomes  considerably  thickened  (five  to  eight 
times  normal),  whitish  in  color,  and  resembles  cartilage  in  its  hard- 
ness and  translucency.  Tubercles,  associated  with  or  without  casea- 
tion, giant,  spindle,  and  small  round  cells  are  encountered  here  with 
more  or  less  regularity;  polymorphonuclear  and  granular  eosinophil 
cells  have  been  seen  in  this  layer  near  the  mucosa,  and  tubercle  bacilli 
in  small  numbers  may  be  found  when  a  sufticient  number  of  sections 
are  examined.  It  is  here  and  in  the  subserosa  that  the  conflict  takes 
place  bersveen  the  tubercular  invasion  and  the  inflammaton,-  reaction 
inaugurated  by  the  system  to  combat  extension  of  the  disease,  and  in 
consequence  there  is  a  piling  up  of  hyperplastic  tissue  in  these  tunics. 

Owing  to  the  fact  that  the  mucosa  and  its  vessels  are  so  markedly 
involved  in  this  form  of  tuberculosis,  some  authorities  maintain  that  it 
is  of  hematogenous  origin. 

The  muscular  tunic  is  also  thickened  in  hyperplastic  tuberculosis 
owing  to  round-celled  infiltration,  and  not  to  anv  increase  in  the  num- 


HYPliKPLASTIC    (hVPKRTROPHIC    NEOPLASTIC)    TUBERCULOSIS       233 

her  and  size  of  llie  nuiscle-fibers.  When  there  is  a  true  hypertrophy 
in  these  cases  it  is  compensatory,  and  takes  place  in  the  dilated  seg- 
ments of  bowel  proximal  to  the  obstructing  mass.  In  neoplastic  tuber- 
culosis the  muscle  bundles  appear  paler  than  normal  and  the  fibers 
are  often  separated  by  connective-tissue  formations,  but  the  changes  in 
the  musculature  is  much  less  marked  than  in  the  tunics  on  either  side. 

The  subserosa  ordinarily  is  extensively  invoked  in  the  hyi)erplastic 
process  and  is  greatly  thickened  by  round-celled  infiltration.  The 
cellular  elements  here  are  the  same  as  in  the  submucosa,  with  the 
exception  of  the  accumulation  of  fat  cells  in  the  vacuolated  spaces. 
Tubercles  are  rarely  found  in  this  tunic,  but  when  seen  present  occa- 
sionally minute  abscesses  formed  through  the  breaking  down  of  caseous 
deposits,  and  when  perforation  takes  place  a  localized  or  general  peri- 
tonitis ensues.  The  peri-  and  endarteritis  always  present  in  tuber- 
cular manifestations  are  pronounced  here  on  account  of  the  vascu- 
larity of  the  subserosa.  C'onrath  holds  there  are  two  types  of  neoplas- 
tic tuberculosis,  viz.,  subserous  and  submucous,  and  that  the  former  is 
more  frequent,  is  caused  by  infected  ileocecal  glands,  and  involves 
other  coats  of  the  bowel  through  lymphatic  extensions. 

The  large  amount  of  hyperplastic  tissue,  together  with  the  fil:)rous 
bands  existing  in  the  subserosa,  are  largely  responsible  for  the  hard, 
tumor-like  formation   noticeable  in   neoplastic  tuberculosis. 

The  peritoneal  coat  is  the  least  changed  of  the  intestinal  tunics,  is 
slightly  increased  in  thickness,  and  may  at  times  become  dotted  over 
with  tubercles  or  involved  by  adhesions  which  distort  the  bowel. 

In  neglected  cases  of  hypertrophic  tuberculosis,  where  round- 
celled  infiltration  is  extensive  and  the  gut  lumen  diminished,  the  in- 
testinal coats  proximal  to  the  stenosis  are  thinned  and  may  be  rup- 
tured or  perforated,  while  the  bowel  is  distended,  or  when  tubercles 
undergo  caseation.  Under  such  circumstances  local  or  general 
infection  takes  place,  and  pyostercoral  abscesses  form  and  empty 
into  other  organs  or  through  the  abdominal  wall. 

Appendiceal  involvement  nearly  always  occurs  in  hyperplastic 
ileocecal  tuberculosis.  Usually  the  involvement  is  confined  to  ad- 
hesions which  bind  it  to  the  tumor  mass  and  angulate  or  displace  it. 
When  the  hyperplasia  attacks  the  appendix  the  process  is  found  more 
frequently  at  the  base  than  the  tip  or  other  parts,  owing  to  exten- 
sion of  the  disease  from  the  ileocecal  region.  The  author  reccntl>' 
attempted  ap{)endicostomy  for  the  relief  of  ulcerative  colitis,  but  this 
procedure  was  abandoned  for  cecostomy  because  of  the  diseased  con- 
dition of  the  appendix,  which  called  for  an  appendectomy.  The 
appendix  was  more  than  four  times  its  normal  size,  indurated,  studded 
here  and  there  with  tubercles,  and  when  opened  the  mucosa  and 
other  tunics  were  found  greatly  thickened  and  composed  largely  of 
filjrous  tissue;  upon  section  it  showed  the  usual  hyperplastic  changes 
common  to  neoplastic  tuberculosis.  Less  frequenth'  the  infection 
occurs  primarily  in  the  appendix  and  extends  to  and  in\ol\-es  the 
cecum  and  adjacent  structures,  and,  when  the  disease  is  \irulent,  per- 


234     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 


foralion  (^f  or,  in  rare  instances,  complete  destruction  of  the  appendix 
ensues. 

Glandular  Involvement  in  Neoplastic  Tuberculosis. — -Ileocecal  aden- 
opathy in  one  form  or  another  invariably  occurs  in  hyperplastic  intes- 
tinal tuberculosis,  manifests  itself  early  in  the  disease,  and  may  be 
limited  to  the  ileocecal  angle,  where  it  is  always  marked  or  extends 
to  lymph-nodes  at  a  considerable  distance  from  active  tubercular 
foci.  In  fact,  enlargements  of  the  mesenteric,  retroperitoneal,  and 
sometimes  omental  glands  have  been  observed  in  these  cases,  but  most 
often  the  nodes  in  the  vicinity  of  the  cecum  and  along  the  ileocecal 
vessels  are  chiefly  affected.  Occasionally  one  finds  single  or  multiple 
small  and  large  glands  bound  up  in  the  inflammatory  mass.  The 
enlargement  of  the  lymph-nodes  may  result  from  a  simple  or  tubercu- 
lar colitis  or  mixed  infection  in  hyperplastic  ileocecal  disease,  or  the 

tubercular  process  may  primarily 
attack  the  glands  and  extend  from 
them  to  the  bowel  or  elsewhere. 
When  the  inflammatory  process  in 
the  glands  is  tubercular  they  may 
become  calcified  and  do  little  dam- 
age, or  caseate,  break  down,  and 
cause  abscesses  and  profound  dis- 
turbances. 

Fibrosclerotic  Tuberculosis 
(Fig.  34). — This  so-called  type  of 
intestinal  tuberculosis  differs  from 
others,  in  that  the  involved  seg- 
ment of  the  bowel  undergoes 
changes  which  primarily  convert  it 
into  a  firm  resisting  tube  (gas-pipe 
intestine)  in  the  absence  of  ulcer- 
ative or  tumor-forming  changes. 
Through  the  action  of  tubercle 
bacilli  alone,  or  in  conjunction 
with  other  pathogenic  micro-organ- 
isms, a  virulent  toxin  is  formed 
which  excites  a  chronic  subacute 
inflammatory  process  within  the 
gut  wall,  limited  principally  to  the 
submucosa,  which  causes  it  and 
the  blood-vessels  to  undergo  connective-tissue  changes  independent 
of  the  formation  of  cicatricial  tissue,  which  converts  the  pliable  intes- 
tine into  a  short  or  long  fibrous  tube. 

When  obstruction  results  from  this  condition  the  mucosa  is  rarely 
ulcerated,  and  when  it  is,  the  lesions  are  secondary.  In  cases  operated 
upon  by  the  author  and  specimens  examined  by  him  presenting  the 
picture  of  fibrosclerotic  tuberculosis  the  mucous  membrane  was 
poorly  nourished,  of  a  pcarlish-gray  color,  and  thrown  into  longitudinal 


Stricture  of  the  rectum  due 
to  chronic  proliferating  stenosing  tubercu- 
lar proctitis  (fibrosclerotic  tuberculosis). 
Note  thickening  of  rectal  wall.  (Author's 
case.) 


GLANDULAR  TURKRCULOSIS 


235 


or  concentric  rings  through  conlractioii  ot  the  outer  tunics,  and  there 
were  no  evidences  of  healed  ulcers.  In  one  case  a  section  was  examined 
and  pronounced  by  the  pathologist  fibrosclerotic  tuberculosis,  horn 
the  presence  of  tubercular  tissue  and  extensive  connective-tissue 
changes  in  the  submucosa. 

It  has  been  customary  to  inchide  this  variety  when  gr(jui)ing 
tubercular  manifestations  of  the  intestine,  and  for  that  reason  the 
writer  has  separately  discussed  fibrosclerotic  or  atrophic  tuberculosis, 
though,  according  to  his  view,  its  pathology  does  not  differ  sufficiently 
from  that  of  the  hyperplastic  type  to  entitle  it  to  individual  considera- 
tion. It  is  true  that  sometimes  the  so-called  tubercular  gas-pipe  in- 
testine is  encountered,  and  the  changes  within  the  gut  cannot  be 
attributed  to  the  cicatricial  tissue  of  healed  ulcers,  nor  is  the  bowel 
encapsulated  by  the  fibro-adipose  covering  present  in  true  neoplastic 
tuberculosis,  but  otherwise  the 
condition  closely  resembles  hyper- 
])lasiic  tuberculosis,  and  it  is 
probal:)ly  a  variation  of  it. 

Again,  it  is  likely  that  man\- 
strictures  ascribed  to  atrophy  or 
sclerotic  changes  have,  in  reality, 
been  induced  by  scar-tissue  fol- 
lowing the  healing  of  ulcers  in 
the  mucosa.  Busse  records  3 
cases  bearing  out  this  argument, 
and  says  that,  upon  the  basis  of 
his  findings,  "there  is  no  proof  of 
a  non-ulcerating  submucous  tu- 
berculosis of  the  intestine,"  and, 
further,  that  "the  previous  exist- 
ence of  ulcers  must  be  assumed 
as  the  cause  of  stricture,"  a 
view  maintained  by  many  modern 
authorities  upon  this  subject. 
From    the    e\idence    at    hand    it 

wcHild  appear  that  the  type  of  tuberculosis  under  discussion  has  not  an 
entity,  but  it  is  a  condition  with  peculiar  features,  which  may  be  in- 
duced either  by  enteric  (ulcerating)  or  hyperplastic  tuberculosis. 

Glandular  Tuberculosis. — This  type  of  tuberculosis  will  recei\e 
but  brief  attention  because  of  its  rarit\-,  its  independence  of  intestinal 
involvement,  and  the  infrequency  with  which  it  causes  diarrhea. 

The  mesenteric  glands  adjacent  to  and  lymph-nodes  situated  at  a 
considerable  distance  from  the  bowel  may  become  secondarily  involved 
in  intestinal  tuberculosis,  or,  less  frecjuently,  they  may  become  infected 
primarily  and  the  disease  extend  to  the  bowel  (Fig.  35). 

Primary  infection  of  the  mesenteric  glands  may  occur  at  an\-  age, 
but  is  most  freciuent  in  females  between  the  ages  of  three  and  ten,  and 
'  Specimen  in  Carnej^ne  Laboratory. 


Fuberculosis    of   the    mesentery 
and  lymph-nodes.' 


236     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

the  group  of  glands  most  commonly  attacked  is  situated  in  the  ileocecal 
region  (ileocecal  adcnopath}-)-  Vautrin  has  recorded  3  cases  of  primary 
invoKement  of  these  glands,  and  maintains  that  the  abundant  follicles 
and  rich  network  of  lymphatics  favor  infection  of  glands  of  this  region. 

It  has  been  shown  elsewhere  that  tubercle  bacilli  can  penetrate 
the  intestinal  wall  when  it  is  healthy  or  diseased,  and  under  such 
circumstances  it  is  easy  for  the  bacilli  to  pass  from  the  bowel  (by 
way  of  the  blood  or  lymph-channels)  to  and  infect  the  mesenteric, 
retroperitoneal,  and  omental  glands  primarily  or  secondarily,  both 
with  and  without  ulceration  of  the  mucosa.  Hemmeter,  in  56  ne- 
cropsies upon  persons  who  died  of  phthisis,  observed  tuberculosis 
of  the  mesenteric,  omental,  or  retroperitoneal  glands  in  12  instances, 
in  6  of  which  the  entire  intestinal  mucosa  was  intact  and  in  4  there  was 
enteritis  or  colitis. 

The  mesenteric  glands,  like  the  intestine,  are  involved  secondarily 
very  much  more  frequently  than  primarily,  and  when  the  disease 
originates  in  the  lymph-nodes  it  is  probably  caused  by  bovine  bacilli 
which  have  gained  entrance  to  the  bowel. 

Concerning  primary  and  secondary  glandular  infection  in  children, 
Carriere  says  that  the  mesenteric  glands  may  become  secondarily 
infected,  and  this  is  the  more  common  type  of  the  disease.  Primary 
tuberculosis  of  these  nodes  was  found  by  him  in  only  2  of  200  cases. 
Among  2000  examined  patients  it  could  be  demonstrated  in  only  9 
per  cent,  of  the  cases. 

Secondary  tuberculosis  of  the  mesenteric  glands  is  common  in 
children,  and  Carriere  observed  it  in  connection  with  pulmonary 
tuberculosis  in  30  per  cent.;  tuberculous  peritonitis,  40  per  cent.; 
tuberculous  enteritis,  20  per  cent.;  tuberculous  glandular  affections, 
5  per  cent.,  and  bone-and -joint  tuberculosis  in  5  per  cent,  of  the  cases. 

One  or  many  of  the  lymph-nodes  may  be  diseased,  and,  accord- 
ing to  circumstances,  the  enlargement  may  present  as  a  minute  or 
large  nodule,  or  single  or  multiple  conglomerate  masses,  which  may 
be  mistaken  for  impactions,  cancer,  and  other  tumor  formations. 
Such  swellings  are  exceptionally  palpable,  but,  as  a  rule,  they  are  not 
detected  except  during  operation  or  at  autopsy.  It  is  well  to  remem- 
ber, however,  that  the  mesenteric  lymph-nodes  may  become  swollen 
as  a  result  of  other  types  of  infection,  and  that  they  are  not  necessarily 
tubercular  even  when  such  a  process  is  present  in  the  lungs,  intestines, 
or  elsewhere. 

Tubercular  glands  behind  the  peritoneum  and  in  the  omentum  or 
mesenteric  folds  may  caseate  and  suppurate,  or,  as  is  usually  the  case, 
undergo  calcareous  degeneration. 

In  the  author's  cases  of  intestinal  tuberculosis  extensive  second- 
ary glandular  involvement  has  generally  been  observed. 

When  the  diseased  glands  are  few  and  small,  mcteorism  may  ensue 
through  interference  to  the  mesenteric  nerves  and  vessels,  but  when 
they  are  large  and  numerous,  intestinal  stenosis  may  result  from 
pressure  or  the  formation  of   contracting  adhesions  and  connective 


PERITONEAL    TUBERCULOSIS  237 

tissue.  The  author  has  observed  one  case  where  the  mesenteric  glands 
were  enlarged  and  the  adjacent  bowel  had  undergone  fibrosis  and 
presented  a  glistening  appearance  and  leathery  feel,  and  there  is  a 
unique  specimen  of  ileocecal  adenopathy  in  the  pathologic  laboratory 
of  Columbia  University  wherein  the  glandular  mass  is  hen's-egg  size 
and  caused  intestinal  obstruction. 

The  enlarged  glands  may  reduce  in  size  spontaneously  or,  when 
tubercular,  undergo  calcification  and  feel  like  bullets  within  the 
mesentery,  or  they  may  suppurate  and  discharge  into  the  bowel  or 
the  peritoneal  cavity,  causing  a  local  or  general  peritonitis. 

When  the  nodes  break  down  or  a  localized  peritonitis  results  from 
other   causes,   they  may  become    agglutinated    to    aduuL-ni    (nils   of 


0^. 


Fig.   36. — Tubercular   deposits   in   the       Fig.  37. — Gastric  tubercular  ulcer.      Wo- 
peritoneum  opposite  ulcers  in  the  small  in-  man  twenty-three,  phthisis.^ 

testine. 

intestine  and  form  a  tumor  mass  discernible  by  palpation  and  inspec- 
tion. 

In  studying  intestinal  tuberculosis  it  is  well  to  bear  in  mind  that 
the  glands  associated  with  and  those  located  at  a  considerable  dis- 
tance from  the  tuberculous  bowel  may  become  affected  primarily  or 
secondarily  in  the  various  types  of  intestinal  tuberculosis. 

Peritoneal  Tuberculosis  (Fig.  36). — The  peritoneum  is  nearly 
al\va\s  invoked  in  intestinal  tuberculosis  incident  to  the  presence  of 
tubercle  bacilli  or  mixed  infection  or  extension  of  the  inflammatory- 
process  from  disease  within  the  bowel,  and  nearly  always  complicated 
by  diarrhea. 

Peritoneal  tuberculosis  is  variable  and  exceedingly  difficult  to 
1  Army  Med.  Museum. 


238      TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

classify  from  cither  a  clinical  or  i:)athologic  standpoint,  but  Murphy's 
arrangement  of  this  type  has  been  generally  accepted,  viz.: 

(i)  Disseminated,  exudative,  miliary,  non-confluent,  or  serous 
(ascitic)  variety. 

(2)  Nodular,  ulcerative,  or  perforative  (the  least  frequent)  variety. 

(3)  Adhesive,  fibroplastic,  cystic,  or  obliterative  variety. 

(4)  Suppurative,  circumscribed,  or  general  mixed  infection. 

One  may  gain  some  idea  of  the  frequency  of  tubercular  peritoneal 
involvement  in  tubercular  subjects  by  studying  the  postmortem  sta- 
tistics of  Cummins,  who  found  this  condition  in  11  per  cent,  of  3405 
autopsies,  and  the  107  cases  investigated  by  Philips,  where  peritoneal 
involvement  was  complicated  by  tuberculosis  of  the  lung  in  99,  intes- 
tine in  80,  and  pleura  in  60  instances. 

Tuberculosis  of  the  Stomach. — Gastric  tuberculosis  (Fig.  37) 
requires  mentioning  here  because  when  the  stomach  is  involved  inde- 
pendently or  with  the  bowel,  indigestion  and  diarrhea  are  annoying 
complications.  The  infection  is  encountered  here  less  often  than  in 
the  upper  small  bowel,  where  it  is  rare,  and  the  museums  contain  but 
few  specimens  of  gastric  tuberculosis  and  not  many  cases  have  been 
reported. 

Gastric  tuberculosis  may  be  primary  or  secondary  and  the  accom- 
panying lesions  unimportant  or  extensive,  and  it  is  usually  mistaken 
for  some  other  disease  or  the  diagnosis  is  not  made  until  it  has  become 
serious. 

Maylard  has  collected  several  interesting  cases  of  gastric  tuber- 
culosis; Ellis  has  reported  2  instances  where  the  disease  was  second- 
ary to  pulmonary  tuberculosis,  and  Clayton  and  Wilkinson  collected 
173  and  reported  43  cases  of  their  own,  discovered  during  autopsies 
upon  tubercular  subjects. 

The  pathology,  symptoms,  diagnosis,  and  treatment  of  gastric 
tuberculosis  are  practically  similar  to  those  of  intestinal  tuberculosis, 
and  do  not  call  for  further  consideration  here. 

Tuberculosis  of  the  Appendix. — Appendiceal  tuberculosis  occurs 
more  often  than  is  generally  supposed,  and  the  appendix  may  be 
primarily  (rare)  or  secondarily  involved,  in  which  case  the  disease 
may  be  limited  to  it  (Fig.  38),  or  extend  to  the  cecum  and  from  thence 
to  the  small  intestine  or  colon.  Tuberculosis  shows  a  predilection  for 
the  appendix  on  account  of  its  structure,  liability  to  catarrhal  inflam- 
mation, richness  in  adenoid  tissue,  lymph-follicles,  and  pathogenic 
bacteria,  imperfect  drainage,  and  its  attachment  to  the  cecum,  the 
most  common  site  of  intestinal  tuberculosis.  Gandiani  says  that  ileo- 
cecal tuberculosis  originates  secondarily  in  most  cases  following 
tubercular  lesions  of  the  appendix,  but  the  concensus  of  opinion  is  that 
the  appendix  usually  becomes  involved  through  extension  of  the  dis- 
ease from  the  cecum. 

Tubercular  foci  here  arc  frequent  in  cases  of  disseminated  intestinal 
tuberculosis,  and  the  appendix  is  tubercular  in  from  i  to  2  per  cent,  of 
all  cases  of  appendicitis.     The  hyperplastic  type  involves  the  appendix 


TUBERCULOSIS    OF    THE    RECTUM 


239 


less  frequently  than  other  forms  of  intestinal  tuberculosis,  and  when 
it  does,  in  most  instances  the  infection  occurs  through  contiguity  with 
the  cecum.  Frequently,  where  the  appendix  is  massed  with  ileocecal 
tubercular  tumors,  it  is  not  diseased,  and  l)ecause  of  this  some  authori- 
ties hold  that  tuberculosis  of  the  appendix  is  rare. 

Of  27  cases  of  bowel  tuberculosis  recorded  by  Eisenbach,  the  appen- 
dix was  involved  in  4.  In  144  autopsies  on  patients  having  tubercular 
appendicitis  Leseur  found  the  api)endix 
was  solely  affected  in  8.3  per  cent; 
Fenwick  and  Dodwell,  in  2000  autop- 
sies upon  tubercular  subjects,  observed 
that  the  appendix  was  involved  solely 
in  the  tubercular  process  in  17  cases, 
and  was  associated  with  lesions  in  other 
parts  of  the  bowel  in  50  per  cent,  of 
the  cases. 

Gandiani  has  recorded  an  interest- 
ing case  of  tubercular  appendicitis  in 
a  girl  twenty  years  of  age,  where  the 
disease  was  in  the  initial  stage  and 
more  fully  developed  than  in  the 
cecum,  from  which  he  argued  that  it 
originated  in  the  appendix  and  in- 
volved the  cecum  secondarily. 

Tuberculosis  of  the  Colon  and 
Sigmoid  Flexure. — The  disease  is  en- 
countered in  the  ileocecal  region  in 
about  85  per  cent,  of  the  cases,  but  in 
the  colon  and  sigmoid  it  usually  occurs 
at  the  points  most  often  subjected  to 
trauma    by    the    feces,    viz.,    hepatic, 

splenic,  and  sigmoid  flexures.     When  the  lesions  are  in  the  sigmoid 
they  are  more  numerous  and  larger  than  elsewhere  in  the  colon. 

Tuberculosis  of  the  Rectum. — Anorectal  tuberculosis  is  quite  com- 
mon, and  the  infection  is  more  difficult  to  control  here  than  when  it  is 
in  the  small  or  large  intestine,  and  is  frequently  complicated  by  abscess 
and  fistula.  Mixed  infection  plays  an  important  part  in  rectosigmoidal 
tuberculosis,  and  persistent  diarrhea,  with  an  abundance  of  pus,  blood, 
and  mucus  in  the  stools,  invariably  complicates  the  disease  here. 

1  Army  Med.  Museum. 


Fig.  3S. 


-Tubercular  ulceration 
the  appendix.' 


CHAPTER   XXI 

TUBERCULAR  ENTERITIS,  COLITIS,   AND  ENTEROCOLITIS 
(INTESTINAL  TUBERCULOSIS',  DIARRHEA   IN  ^Continued) 

SYMPTOMS,  COMPLICATIONS,   SEQUELS 

General  Remarks. — In  many  respects  the  symptoms  and  complica- 
tions of  bowel  tuberculosis  are  the  same  as  those  produced  by  other 
inflammatory  and  ulcerative  aftections  of  the  intestine,  the  most 
prominent  of  which  are  diarrhea,  intermittent  attacks  of  abdominal 
tenderness,  pain,  cramps,  and  the  presence  of  mucus,  pus,  and  blood 
in  the  stools.  What  has  been  said  applies  more  particularly  to  the 
disease  in  its  incipient  stage,  because,  when  it  is  more  fulK"  developed, 
the  patient  presents  a  sallow  complexion  and  the  usual  characteristic 
appearance  of  the  tubercular  subject,  but  these  peculiarities  may  be 
mistaken  for  other  forms  of  enteritis  and  colitis  accompanied  by  mixed 
infection  and  auto-intoxication,  where  the  patient  presents  an  un- 
healthy appearance  and  other  manifestations  which  closely  resemble 
those  of  bowel  tuberculosis. 

The  differentiating  symptoms  between  intestinal  tuberculosis  and 
other  ailments  likely  to  be  mistaken  for  it  have  been  outlined  in  the 
following  chapter. 

The  manifestations  induced  by  bowel  tuberculosis  are  similar  in 
some  and  differ  in  other  cases,  because  of  the  van,-ing  types  of  the 
infection.  They  also  var^'  in  all  stages  of  the  disease  and  when  the 
lesions  are  located  in  different  segments  of  the  bowel.  The  disturb- 
ances which  accompany  tuberculosis  of  the  small  intestine  are  less 
severe  than  those  induced  by  the  disease  at  the  ileocecal  region  or 
colon,  and  ulcerative  and  neoplastic  lesions  situated  in  the  lower  sig- 
moid and  rectum  excite  a  more  intense  t\'pe  of  diarrhea,  pain,  and 
tenesmus,  and  the  stools  contain  a  greater  amount  of  pus.  blood,  and 
mucus  than  when  the  foci  are  in  the  upper  colon. 

In  all  forms  of  intestinal  tuberculosis  the  symptoms  are  fewer 
and  less  severe  in  the  earlier  stages  and  when  the  infection  is  mild 
than  when  the  disease  is  \-irulent  or  has  fully  developed.  Tubercu- 
losis would  not  induce  such  distressing  manifestations  nor  terminate 
fatally  so  often  were  it  not  for  the  mixed  infection  incited  by  the 
pathogenic  intestinal  micro-organisms  as  soon  as  the  continuity  of  the 
mucosa  has  been  broken,  a  complication  which  occurs  in  all  forms  of 
this  disease,  but  is  more  marked  in  enteroperitoneal  and  ulcerative 
types,  where  the  denuded  areas  are  numerous  and  large. 

While  it  is  true  that  bowel  tuberculosis  ma\-  originate  primarily  in 
the  gut.  the  fact  remains  that  in  most  instances  it  is  secondary  to  dis- 
ease in  the  lungs  and  other  organs,  consequently,  in  making  a  diag- 
nosis it  is  necessary  to  bear  in  mind  that  ver>'  often  the  symptom- 
240 


ENTERIC    (uLCRRATIVe)    AND    ENTEROPERITONEAL    TUBERCULOSIS      24I 

complex  is  made  up  of  tlic  manifestations  arising  from  tubercular  foci 
in  both  the  lungs  and  bowel;  hence  they  are  more  apt  to  be  confused 
than  when  either  the  one  or  the  other  is  involved.  Knowing  this,  it 
is  easy  to  understand  why  the  destructive  process  causes  less  suffer- 
ing and  progresses  more  slowly  in  primary  than  secondary  intestinal 
tuberculosis,  where  the  patient  is  already  in  a  (k-jjlorable  condition 
from  phthisis  before  the  sputum  infects  the  bowel,  following  which 
rapid  decline  and  death  ensue  unless  the  disease  is  promptly  arrested. 

In  so  far  as  the  intestine  is  concerned  the  origin  of  the  disease  is 
unimportant,  because  the  clinical  picture  presented  by  the  intestinal 
lesions  in  the  various  forms  of  tuberculosis  is  the  same  in  both  primary 
and  secondary. 

Before  considering  the  symptomatology  of  the  individual  forms  of 
intestinal  tuberculosis,  the  author  would  recall  that,  when  the  lungs 
are  involved,  the  patient  suffers  from  an  evening  temperature,  night- 
sweats,  emaciation,  impaired  digestion,  discomfort  in  the  chest,  cough, 
hemorrhages,  and  the  usual  indications  of  phthisis  in  addition  to  diar- 
rhea and  other  gastro-intestinal  disturbances. 

Enteric  (Ulcerative)  and  Enteroperitoneal  Tuberculosis. — Because 
of  the  similarity  of  the  clinical  pictures  produced  by  ulcerative  (granu- 
lar) and  enteroperitoneal  tuberculosis  of  the  intestine,  particularly 
in  their  earlier  stages,  it  would  be  impracticable  to  consider  their 
symptomatology  separately.  In  fact,  one  encounters  great  difficulty 
in  distinguishing  betw'een  the  manifestations  induced  by  them  and 
other  types  of  enterocolitis. 

To  avoid  repetition  the  author  in  his  general  remarks  upon  intes- 
tinal tuberculosis  pointed  out  the  manifestations  in  these  cases  when  the 
lungs  are  involved,  and  nothing  more  is  necessary  here  than  to  empha- 
size the  symptoms  which  arise  from  foci  in  the  bowel  and  other  organs. 

In  the  incipient  stages  the  unimportant  symptoms,  such  as  dimin- 
ished appetite,  imperfect  digestion,  softening  of  the  evacuations  or 
occasional  slight  diarrheal  attacks  and  discomfort  in  the  region  of  the 
navel,  are  not  suf^ciently  characteristic  to  lead  one  to  suspect  the 
tubercular  nature  of  the  disease,  and  they  are  usually  ascribed  to 
gastro-intestinal  catarrh  or  colitis  from  other  causes.  When  the 
tubercular  process  makes  rapid  strides,  characteristic  manifestations 
quickly  become  obvious,  but  this  is  exceptional  and,  as  a  rule,  the 
symptom-complex  gradually  Ijecomes  exaggerated  until,  at  the  end  of 
a  few  weeks  or  (at  most)  months,  the  clinical  picture  is  sufficiently  clear 
to  cause  one  to  suspect  intestinal  tuberculosis,  particularly  when  the 
patient  already  has  phthisis.  By  this  time  he  looks  very  ill,  has  lost 
considerable  weight  and  strength,  and  suffers  from  malaise,  has  anemia, 
a  sallow  complexion,  poor  appetite,  concentrated  urine,  furred  tongue, 
foul  breath,  indigestion,  a  slight  elevation  of  temperature,  increased 
pulse-rate,  occasional  night-sweats,  is  restless  and  worried  o\'er  his 
condition,  and  suffers  from  diarrhea,  a  discharge  of  pus,  l)lood,  and 
mucus  in  the  stools,  abdominal  pain,  tenderness,  and  gas  distention, 
which  require  separate  consideration  on  account  of  their  importance. 
16 


242     TUBERCLXAR    ENTERITIS,    COLITIS.    ENTEROCOLITIS.    DIARRHEA    IN 

Diarrhea  is  the  chief  symptom  of  bowel  tuberculosis,  varies  in 
different  cases  according  to  the  stage,  location,  and  extent  of  the  dis- 
ease, and  the  presence  or  absence  of  other  complicating  intestinal 
affections. 

In  the  incipient  stage,  where  the  inflammation  dominates  the 
ulcerative  process,  the  movements  become  softer,  contain  a  small 
amount  of  mucus,  and  may  take  place  with  normal  or  increased  fre- 
quency, but  later,  through  the  formation  of  new  and  extension  of  old 
lesions  and  the  part  played  by  mixed  infection,  an  aggravated  type  of 
diarrhea  develops,  and  the  patient  may  have  an\"v\here  from  eight  to 
fifteen  movements  within  tAvent\-four  hours,  principally  at  night,  on 
account  of  which  this  condition  has  been  designated  by  some  authori- 
ties as  diarrhea  nocturyia. 

In  some  instances  diarrhea  may  continue  over  a  considerable 
period,  but  usually  it  is  intermittent,  during  which  time  the  patient 
may  not  have  more  than  two  or  three  stools  daily,  and  then,  through 
action  of  the  food  or  other  inexplicable  cause,  there  is  an  acute  crisis 
accompanied  by  cramping  pain,  sensation  of  weakness,  anorexia,  and 
abdominal  distention,  which  is  followed  by  the  escape  of  the  gas  and 
several  fluid  movements  having  a  penetrating,  fetid  odor,  and  contain- 
ing remnants  of  undigested  food  and  fats.  Freeing  the  bowel  of 
retained  foul  gases  and  feces  brings  immediate  relief.  When  the  dis- 
ease is  not  arrested  the  crises  gradually  increase  in  number  and  severity 
until  diarrhea  is  persistent  and  the  griping  pains  are  almost  continuous. 
Under  such  circumstances,  opiates,  bismuth,  and  other  therapeutic 
remedies,  administered  to  alleviate  suffering  and  diminish  frequency 
of  the  evacuations,  frequently  fail  to  relieve  the  patient.  The  move- 
ments are  semisolid,  at  first  mushy  or  lumpy  and  light  colored,  and 
finally  fluid,  and  contain  mucus,  blood,  and  pus  in  amounts  corre- 
sponding with  the  number  and  size  of  the  lesions. 

When  a  vessel  of  considerable  size  and  high  up  is  involved  the  feces 
frequently  resemble  coffee-grounds  (black  diarrhea),  owing  to  free 
bleeding  and  contained  clotted  blood.  Stools  of  fresh  blood  indicate 
one  or  more  bleeding  ulcers  in  the  rectum,  but  when  clear  blood  precedes 
the  movements,  it  is  suggestive  of  hemorrhoids,  an  ulcer,  or  fissure  at 
the  anal  margin.  Pus  and  blood  are  found  less  often  and  in  smaller 
quantities  in  tubercular  than  other  t\'pes  of  colitis,  excepting  catarrhal. 
Frequently  the  blood  in  the  evacuations  of  persons  suffering  from  in- 
testinal tuberculosis  is  occult,  and  is  found  only  by  the  microscope  as 
hematin  cn.-stals  and  blood-cells. 

The  author  has  often  obser\-ed  that  when  tubercular  lesions  are 
situated  in  the  sigmoid  flexure  or  rectum  they  cause  a  much  greater 
frequency  and  fluidity-  of  the  stools  than  when  located  in  the  colon  or 
small  bowel,  and  that  ulcerative  affections  are  always  more  pro- 
nounced in  the  colon  than  in  the  small  intestine,  the  ulcers  being  larger 
and  more  numerous.  The  frequency  and  solidity  of  the  stools  are 
modified  in  two  ways,  \  iz.,  through  impairment  to  or  destruction  of 
large  areas  of  mucosa,  which  limits  the  absorption  of  water  and  causes 


ENTERIC    (ulcerative)    AND    ENTEROPERITONEAL    TUBERCULOSIS      243 

irritation  to  the  exposed  nerves;  this  reflexly  leads  to  abnormal  peris- 
talsis, glandular  secretion,  and  the  pouring  of  mucus  into  the  bowel, 
which  softens  the  fecal  content  and  increases  the  number  of  evacua- 
tions. When  the  small  intestine  is  involved  the  movements  are  fewer 
in  number  except  when  the  colon  is  also  ulcerated. 

In  these  cases  there  ma\-  be  as  much  irritation  and  the  contents 
are  rapidly  rushed  through  the  small  bowel  on  account  of  the  in- 
creased peristalsis,  but,  owing  to  their  longer  retention  in  the  healthy 
colon,  the  watery  content  of  the  stool  is  absorbed  and  the  feces  may 
be  evacuated  soft  or  firm  in  consistence.  In  most  instances,  how- 
ever, the  large  intestine,  through  infection  or  irritation  indticed  by  the 
discharges  from  above,  becomes  diseased  when  the  stools  are  materi- 
ally increased. 

Apart  from  the  influence  of  location,  the  number  of  daily  evacua- 
tions in  intestinal  tuberculosis,  the  degree  of  digestive  disturbance, 
the  amount  of  tenderness  and  pain,  and  the  quantity  and  character  of 
the  discharges,  pus,  mucus,  and  debris,  bear  a  direct  ratio  to  the 
extent  of  the  lesions,  viz.,  they  are  more  aggravated  when  the  ulcers 
become  numerous,  deep,  and  extensive,  and  less  annoying  when  the 
lesions  are  few,  small,  and  superficial. 

While  diarrhea  is  the  pathognomonic  s\mptom  of  bowel  tuberculo- 
sis, it  is  well  to  bear  in  mind  that  occasionally  this  class  of  patients  do 
not  suffer  from  frequent  movements,  but  are  troubled  with  obstipa- 
tion or  constipation  alternating  with  diarrhea,  induced  by  enterospasm, 
excited  through  ner\e  irritation  in  the  ulcerative  and  enteroperitoneal 
types  where  the  mucosa  is  denuded  or  obstruction  caused  by  the 
tumor  in  hyperplastic  tuberculosis;  or  possibly,  through  mixed  infec- 
tion, a  virulent  toxin  is  produced  in  the  gut  which  reaches  the  nerve- 
centers  and  produces  a  paralytic  or  inhibitory  influence  upon  the 
nerves  controlling  the  motor  apparatus  of  the  gut,  resulting  in  irregu- 
lar and  infrequent  e\-acuations.  In  several  cases  where  constipation 
was  marked  the  inner  coats  of  the  intestine  w'ere  studded  with  small 
lesions  or  extensive  denuded  areas  of  several  coalesced  ulcers,  or  by  an 
obstruction  induced  by  a  tubercular  neoplastic  swelling. 

Pain  and  Tenderness. — Pain  in  one  form  or  another  is  encountered 
in  all  types  and  stages  of  tuberculosis,  but  its  character  and  severity 
depend  largely  upon  the  following  conditions,  viz.:  (a)  the  degree  of 
digestive  disturbances  and  {b)  the  number,  extent,  and  location  of  the 
gut  lesions.  The  most  intense  suffering  (so-called  acute  crises  with 
griping  pains)  is  usually  incited  by  indigestible  food,  which  causes  the 
formation  of  irritating  gases  and  enterospasm  accompanied  by  agon- 
izing, sickening,  disseminated  pain,  which  continues  until  the  putre- 
fying food  and  gases  are  expelled.  Between  attacks  the  patient  usu- 
ally feels  uncomfortable  or  occasionally  suffers  pain  in  the  region  of  the 
navel.  During  crises,  peristalsis  is  active,  and  the  patient  complains 
of  loud  intestinal  noises,  and,  when  enterospasm  is  a  complication, 
the  bowel  is  rigid  and  vermicular  movements  in  the  proximal  intestine 
can  often  be  seen  or  felt  through  the  parietes. 


244     TUBERCULAR    ENTERITIS.    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

Extensive  ulcers  have  been  revealed  at  autopsies  that  caused  little 
if  any  pain  during  life,  but,  as  a  rule,  it  will  be  found  that  the  patient's 
suffering  bears  a  direct  ratio  to  the  extent  of  the  destructive  process. 
Aluch  of  the  discomfort  complained  of  is  caused  by  the  irritating  dis- 
charge which  remains  in  contact  with  the  ulcers  or  passes  over  them. 
Occasionalh"  some  lesions  are  sluggish,  while  others  are  extremely 
sensitive  to  the  discharge  and  bowel  contents,  which  explains  why  it  is 
that  the  patients  sometimes  complain  of  intense  pain  at  a  definite 
point  along  the  bowel  preceding,  during,  and  following  an  evacuation. 
Naturally,  when  ulcers  are  numerous  and  scattered  throughout 
long  segments  of  gut,  suffering  is  proportionateh'  greater,  and  it  is 
in  this  type  of  cases  that  one  observes  tendeniess  upon  pressure 
throughout  the  length  of  the  colon  and  often  over  the  entire  abdomen, 
but  in  some  instances  the  soreness  is  attributable  to  backed-up  gases 
or  enterospasm.  Pain  and  tenderness  are  usually  emphasized  in  the 
lower  colon,  sigmoid,  and  rectum,  because  by  the  time  the  feces  reach 
these  parts  they  are  firm  or  nodular,  difficult  to  propel,  and  cause 
trauma  to  the  ulcers  in  their  downward  passage.  Lesions  situated  in 
the  lower  rectum  and  at  the  anus  invariably  induce  greater  pain  than 
when  higher  up  because  here  the  bowel  is  more  bountifully  supplied 
with  senson.-  ner\-es,  it  is  ver\'  narrow,  and  surrounded  by  the  muscles 
which  contract  and  produce  sphincteralgia  when  the  ulcers  are  trauma- 
tized during  defecation. 

The  author  has  observed  that  in  ulcerative  (enteric)  and  entero- 
peritoneal  intestinal  tuberculosis  crises  occur  more  frequently,  last 
longer,  and  cause  greater  suffering  when  there  is  an  enterocolitis  than 
when  the  lesions  are  confined  to  the  large  bowel,  and  that  comparative 
slight  gas  accumulations  within  the  gut  often  induce  intense  pain,  while 
filling  of  the  bowel  with  water  or  an  irrigating  solution  does  not, 
which  would  indicate  that  the  pain  was  not  due  to  the  distention,  but 
to  the  irritating  qualits'  of  the  gas.  The  rectum  is  nearly  always  di- 
lated in  diarrheal  subjects  and  feels  like  a  gas-filled  cavity,  while  in 
constipation  the  reverse  is  true,  and  the  finger  comes  in  contact  with 
the  rectal  wall  as  soon  as  introduced. 

Owing  to  repeated  or  continuous  gas  distention  many  sufferers 
from  intestinal  tuberculosis  present  a  bulging  abdomen  not  unlike 
the  pot-belly  of  the  enteroptotic  subject,  but  exceptionally  the  ab- 
dominal wall  is  contracted.  This  class  of  sufferers  have  a  habit  of 
rubbing  the  belly,  probably  because  through  the  massage  the>-  are 
able  to  work  the  gas  downward,  to  be  expelled,  while  others  obtain 
relief  by  leaning  over  and  pressing  the  abdomen  against  the  legs  during 
the  crises.  When  the  tubercular  process  is  extensive  and  inflamma- 
tion is  acute  the  abdomen  is  often  firyn  or  rigid  through  muscular 
contraction  incited  by  reflex  impulses,  and  not  as  a  result  of  accumu- 
lated gas. 

Walsh  lays  stress  upon  this  manifestation,  and  has  compiled  statis- 
tics to  show  the  relative  frequency  with  which  diarrhea,  abdominal 
pain,  tenderness  upon  pressure,  and  rigidity  of  the  abdominal  muscles 


enti-:ric  (ulcerative)  and  enteroperitoneal  tuberculosis    245 


occur  in  tuberculosis.  He  found  that  of  76  patients  who  had  tuber- 
cular ulcers  of  the  intestine,  30.6  per  cent,  had  tenderness,  25  per  cent, 
abdominal  rigidity,  and  6.58  per  cent,  all  four  symptoms,  while  in  the 
remaining  24  cases  of  intestinal  tuberculosis,  where  there  were  no  ulcers, 
tenderness  was  manifest  in  29.2  per  cent.,  rigidity  in  25  per  cent.,  and 
diarrhea,  abdominal  pain,  tenderness,  and  rigidity  in  4  per  cent. 

The  author  has  often  obser\ed  the  tightness  of  the  abdominal  wall, 
but  has  not  encountered  muscular  rigidity  with  anything  like  the 
frequency  with  which  it  occurred  in  Walsh's  cases. 

Ulcerative  and  enteroperitoneal  tuberculosis,  like  the  neoplastic 
form,  occurs  most  frequently  at  the  ileocecal  angle,  and  when  the 
process  is  acute  or  involves  the  appendix,  ileocecal  tuberculosis  in  the 
earlier  stages  has  been  mistaken  for  appendicitis. 

When  intestinal  tuberculosis  is  permitted  to  reach  the  final  stages 
through  extension  of  the  caseating  and  ulcerative  process,  it  extends 
deep  into  the  intestinal  tunics  or  perforation  takes  place,  circumscribed 
or  general  peritonitis,  abscess  and  fistukc,  opening  through  the  abdo- 
men in  the  right  iliac  region  are  complications,  or  the  patient  may  die 
from  sepsis,  exhaustion  consequent  upon  the  diarrhea,  or  from  phthisis, 
where  intestinal  infection  is  secondary  to  phthisis. 

Enteroperitoneal  extends  very  rapidly,  is  extremely  difficult  to 
control,  and  is  complicated  by  annoying  or  dangerous  sequelcC  more 
frequently  than  enteric  or  ulcerative  intestinal  tuberculosis.  In  both 
types  the  deplorable  state  of  the  bowel  in  the  later  stages  is  attribut- 
able mainly  to  mixed  infection  induced  by  pathogenic  bacteria  (especi- 
ally the  Bacillus  coli  communis)  normal  inhabitants  of  the  gut.  Un- 
complicated tubercular  lesions  extend  slowly  and  are  inclined  to  re- 
main limited,  but  progress  rapidly  and  produce  ugly,  deep,  irregular, 
excavated,  ulcerated  areas  when  mixed  dominates  tubercular  infection. 

Enteric  (granular,  ulcerative)  tuberculosis  is  rarely  accompanied 
by  the  formation  of  abdominal  or  ischiorectal  abscess  and  fistula,  be- 
cause, as  a  rule,  it  is  limited  to  the  mucosa,  but  enteroperitoneal  is, 
because  all  the  intestinal  tunics  are  involved.  They  are  compara- 
tively rare  complications  of  colonic  tuberculosis  because  the  gut  is  often 
protected  by  peritoneal  adhesions,  but  are  common  in  the  rectal  region 
owing  to  the  absence  of  the  serous  covering. 

Walsh  has  compiled  a  table  to  show  the  frequency  with  which 
tuberculosis  in  the  different  segments  of  the  intestine  is  complicated  by 
abscess,  viz. : 


Ischiorectal  Abscess. 

Present. 

Absent. 

Not  recorded. 

Ulceration  of  small  intestine 

0 
0 

8 

0 

I 

13 
12 

41 
I 

22 

0 

Ulceration  of  large  intestine 

Ulceration  of  botli  large  and  small  intestine. . . 
Ulceration  of  rectum 

2 
0 
0 

Absence  of  ulceration 

0 

246     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

When  periproctitis  takes  place  and  there  is  an  abscess  forming,  the 
patients  complain  of  chilly  sensations,  sharp  rise  in  temperature,  feel- 
ing of  malaise,  and  continuous  throbbing  pain,  symptoms  which  disap- 
pear as  soon  as  the  pus  has  been  evacuated  or  finds  an  outlet  through 
the  bowel  or  ischiorectal  fossa. 

Rarely  enteric  and  enteroperitoneal  lesions  have  been  known  to 
improve  under  treatment  or  heal  spontaneously,  but,  as  a  rule,  partial 
or  complete  stenosis  ensues,  owing  to  the  formation  and  contraction  of 
scar-tissue  at  the  site  of  the  ulcers,  which  induces  the  ordinary  mani- 
festations of  chronic  intestinal  obstruction. 

The  condition  of  patients  afflicted  with  intestinal  tuberculosis  is 
frequently  aggravated  by  the  presence  of  papillomatous  excrescences 
and  cutaneous  hemorrhoids  where  irritating  discharges  constantly 
pour  over  the  mucosa  and  anal  skin. 

While  the  mesenteric  almost  invariably,  and  the  retroperitoneal 
and  omental  lymph-nodes  occasionally,  become  enlarged,  they  pro- 
duce no  symptoms  except  tenderness  upon  pressure  and  palpable 
swellings  unless  they  caseate  and  break  down,  under  which  circum- 
stances there  is  a  rise  in  the  temperature,  often  followed  by  circum- 
scribed peritonitis  and  the  formation  of  an  abscess  which  opens  into 
the  abdominal  cavity  or  drains  into  the  bowel  or  through  the  abdomi- 
nal wall. 

The  author  has  observed  cases  where  there  was  general  miliary 
tuberculosis  that  simultaneously  involved  the  intestine  and  other 
parts,  accompanied  by  a  marked  elevation  of  temperature,  emacia- 
tion, and  profound  gastro-intestinal  disturbances,  which,  in  spite  of 
treatment,  soon  terminated  fatally,  and  he  has  treated  other  patients 
where  the  disease  was  apparently  primary  in  the  bowel,  but  later  ex- 
tended to  other  organs,  all  of  whom  died. 

Symptoms  of  Hyperplastic  (Neoplastic)  Tuberculosis. — The  symp- 
toms of  hyperplastic  (neoplastic)  or  ileocecal  tuberculosis  in  the  small 
bowel  resemble  those  of  other  types  of  the  disease,  but  when  the 
colon,  sigmoid,  or  rectum  are  involved,  neoplastic  tuberculosis  pre- 
sents manifestations  which  are  fairly  characteristic,  but  they  var^-  in 
the  different  stages  of  the  disease. 

In  cases  treated  by  the  author  definite  symptoms  were  not  mani- 
fest until  eight  months,  two  and  five  years  after  the  intestinal  dis- 
turbance started.  When  studying  the  symptomatolog^•  of  this  affec- 
tion it  is  well  to  bear  in  mind  that  it  is  tumor  forming,  and  causes 
a  varying  degree  of  obstruction,  reflex  phenomena,  and  in  the  later 
stages  constitutional  manifestations,  dyspepsia,  loss  of  weight,  and 
irregular  evacuations,  w'hich  contain  mucus  except  when  there  is 
ulceration  or  the  tumor  has  broken  down,  when  the  feces  are  admi.xed 
with  mucus,  pus,  blood  and  tissue  debris,  and  have  a  disgusting 
odor. 

At  the  onset  of  the  trouble,  which  is  insidious,  there  is  an  inex- 
plicable slight  disturbance  in  the  alimentary  tract  that  cannot  be 
located  in  the  stomach  or  intestine,  and  which  does  not  interfere  with 


S\TVIPTOMS    OF    HYPERPLASTIC    (NEOPLASTIC)     TUBERCULOSIS      247 

the  appetite  or  bowel  movements.  At  the  end  of  a  few  weeks  or  months 
progress  of  the  disease  is  indicated  by  a  faihng  appetite,  irritable 
stomach  and  intestine,  slight  discomfort,  sinking  sensation  in  the 
abdomen,  and  occasional  slight  attacks  of  diarrhea.  Later,  when 
the  swelling  has  assumed  proportions  sufficient  to  interfere  with  the 
fecal  current  and  the  circulation,  lymphatics,  and  nervous  apparatus 
of  the  gut,  local  and  general  manifestations  of  the  disease  become  more 
apparent.  Either  through  direct  or  reflex  disturbances  to  the  digest- 
ive tract  mild  crises  occur,  during  which  the  patient  has  se\"cre  indi- 
gestion, becomes  nauseated  and  vomits,  suffers  from  cramps,  intesti- 
nal gas  distention,  frequent  fluid  or  lumpy  evacuations  containing 
considerable  mucus,  a  feeling  of  discomfort  and  tenderness  in  the 
right  iliac  fossa,  and  rigidity  of  the  abdominal  muscles.  Months  later, 
or  from  one  to  three  years  from  the  time  the  patient  became  ill,  the 
manifestations  of  the  disease  become  sufficiently  characteristic  to 
enable  one  to  group  them  and  complete  the  diagnosis.  By  this  time 
the  subject  has  a  tubercular  complexion,  has  lost  considerable  weight, 
runs  an  occasional  temperature,  has  intermittent  attacks  of  colic, 
diarrhea,  the  stools  containing  undigested  food  remnants,  fat,  a  large 
amount  of  mucus,  and  sometimes  pus  and  blood  when  there  are  ulcers, 
and  the  patient  worries  over  his  condition,  believing  it  to  be  cancerous. 
In  addition,  he  complains  of  a  sensation  of  blockage  in  the  right 
side,  and  usually  a  fair-sized,  firm,  fixed,  oval  tumor  can  be  seen 
or  felt  in  the  ileocecal  region. 

Examination  reveals  a  firm,  oval,  tender  tumor  in  the  right  iliac 
fossa,  with  sometimes  palpable  retroperitoneal  or  mesenteric  lymph- 
nodes  in  the  ileocecal  angle,  or  a  large  irregular  swelling  when  the 
appendix,  cecum,  ileum,  and  adjoining  structures  become  enmassed. 
The  neoplasms  frequently  can  be  easily  felt  or  seen  bulging  the  ab- 
dominal wall.  Owing  to  the  partial  obstruction  induced  by  the  growth 
the  patient  suffers  from  obstipation  or  constipation,  alternating  with 
diarrhea,  between  the  crises. 

In  the  final  stages  of  the  disease  there  is  almost  continuous  diarrhea 
because  only  fluid  feces  can  pass  the  obstruction,  and  the  patient  suft'ers 
intensely  from  griping  pains,  fecal  impactions,  putrefaction,  and 
retained  gases;  all  of  which  conditions  favor  a  general  septic  condition, 
pyrexia,  rapid  pulse,  and  other  evidences  of  auto-intoxication,  and  he 
becomes  rapidly  weaker  and  emaciated  through  the  frequent  evacua- 
tions and  discharges,  which  often  contain  mucus,  pus,  and  blood  in 
consequence  of  the  breaking  down  of  the  mesenteric  glands  or  bowel 
wall  through  caseation,  or  the  formation  of  deep  ulcers  resulting  from 
combined  tubercular  and  mixed  infection  present. 

Occasionally  the  destructive  process  extends  until  a  perforation 
occurs  which  results  in  peritonitis  or  the  formation  of  simple  or  pyoster- 
coral  abscesses,  which  may  remain  circumscribed  or  form  fistulous 
sinuses  which  open  externally  in  the  iliac  fossa  or  at  the  navel  in  chil- 
dren. Even  yet  the  prognosis  is  fairly  good  when  the  involved  gut  is 
excised  and  the  sinus  is  dissected  out,  but  if  the  disease  is  not  now 


24-8     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

arrested  the  patient  will  soon  die  from  exhaustion  as  a  result  of  mal- 
nutrition, infection,  or  diarrhea. 

In  addition  to  the  manifestations  already  enumerated,  when 
acute  attacks  are  excited  by  the  administration  of  purgatives  or  other 
causes,  meteorism,  gurgling,  and  splashing  sounds  can  be  detected  in 
the  dilated  proximal  end  of  the  ileum  and  pain  is  severe  throughout 
the  abdomen,  which  is  usually  protuberant. 

The  symptoms  of  hyperplastic  and  other  types,  of  tuberculosis 
in  the  colon  and  sigmoid  flexure  are  the  same  as  when  the  ileocecal 
region  is  attacked,  but  when  the  rectum  is  involved  all  symptoms  are 
worse,  and  the  patient  complains  bitterly  of  sensations  of  fulness, 
weight  and  bearing-down  in  the  bowel,  and  tenesmus  at  stool. 

The  symptoms  of  peritoneal  tuberculosis  may  be  insidious,  under 
which  circumstances  they  are  characterized  by  emaciation,  sallow 
complexion,  anorexia,  coated  tongue,  abdominal  discomfort,  obstinate 
diarrhea  or  constipation,  tenderness  upon  pressure,  slightly  elevated 
evening  temperature  and  a  gradually  quickening  pulse,  or  the  attack 
may  come  on  suddenly  as  the  result  of  an  acute  exacerbation  or  per- 
foration when  the  symptoms  become  urgent,  the  patient  has  a  high 
temperature,  night-sweats,  and  other  evidences  of  pus  formation, 
viz.,  fast  pulse,  generalized  abdominal  pain  and  distention,  and  fluid 
in  the  abdomen,  which  has  a  protuberant  appearance  and  doughy 
feel. 

In  fibrosclerotic  tuberculosis  the  symptoms  are  the  same  as  in 
stricture  of  a  corresponding  segment  of  the  bowel  from  other  causes, 
viz.,  constipation  alternating  with  diarrhea,  recurring  fecal  impac- 
tion and  gas  distention,  occasional  colic,  malnutrition,  muddy  or  sal- 
low complexion,  frequent  attacks  of  indigestion,  rumbling  within  the 
gut,  exaggerated  peristalsis,  and,  when  the  block  is  in  the  lower  sig- 
moid or  rectum,  an  incessant  desire  to  stool,  bearing-down  pains,  and 
an  unrelie^'ed  sensation  following  stool.  In  this  form  of  bowel  tuber- 
culosis, diarrhea  persists  because  fluids  only  can  pass  the  involved 
segment,  but  blood,  pus,  and  mucus  in  the  evacuations  are  not  so 
abundant  because  stricture  formation  here  is  not  preceded  by  ex- 
tensive ulceration.  The  general  condition  of  patients  suffering  from 
fibrosclerotic  tuberculosis  is  fairly  good  because  the  disease  is  not 
nearly  so  exhausting  as  enteric  (ulcerative)  and  enteroperitoneal  tuber- 
culosis. 

The  symptoms  of  intestinal  peritoneal  tuberculosis  are  indefinite 
until  peritonitis  ensues.  Usually  it  causes  more  or  less  bowel  distor- 
tion, and  is  not  suspected  until  the  abdomen  is  opened;  hence  it  is 
usually  mistaken  for  other  types  of  intestinal  tuberculosis. 

The  symptoms  of  glandular  tuberculosis  are  about  the  same  as  those 
caused  by  tubercular  infection  of  the  colon,  except  that  gas  distentions 
are  more  frequent  and  pronounced,  the  glands  are  occasionally  pal- 
pable, and  diarrhea,  accompanied  by  mucus,  pus,  and  blood  in  the 
stools,  is  less  annoying,  owing  to  the  fact  that  the  mucosa  is  not  ulcer- 
ated. 


COMPLICATIONS    AND    SEQUEL.E    OF    INTESTINAL    TUBERCULOSIS      249 

Complications  and  Sequelae  of  Intestinal  Tuberculosis. — Having 
outlinetl  ihc  general  and  local  symptoms  as  encountered  in  the  \arious 
stages  of  the  different  types  of  bowel  tuberculosis,  the  author  will  now 
briefly  discuss  the  more  common  and  serious  complications  and  sequelae 
which  may  result  from  intestinal  tuberculosis,  viz.: 

(i)  Stricture. 

(2)  Peritonitis  with  and  without  perforation. 

(3)  Adhesions,  kinks,  and  twists. 

(4)  Abdominal  and  anorectal  abscesses-  and  fistukc. 

(5)  Generalization  of  the  infection  (miliary  tuberculosis). 

(6)  Carcinomatous  grafting  upon  the  tubercular  process. 
Stricture. — The  most  frequent,  annoying,  and  difficult  to  cure  of 

the  resultant  disturbances  of  intestinal  tuberculosis  is  stenosis,  a  con- 
dition sometimes  encountered  in  all  parts  of  the  intestine  in  the  differ- 
ent types  of  the  disease.  This  type  of  stricture  may  be  met  with  in 
any  country,  at  all  ages,  in  both  sexes,  and  remains  through  life  to 
cause  partial  or  complete  obstruction  unless-  cured  by  surgical  inter- 
vention. 

Like  other  intestinal  tubercular  affections,  stricture  is  encountered 
most  often  in  persons  between  twenty  and  forty  years  of  age,  although 
one  case  has  been  observ^ed  in  a  child  three  and  one-half  and  another 
in  a  man  sixty-eight  years  old. 

This  type  of  stenosis  is  located  fairly  often,  in  the  small  intestine, 
an  evidence  of  which  is  to  be  found  in  the  statistics  of  Berney,  who,  as 
far  back  as  1899,  collected  70  cases;  since  then  numerous  cases  have 
been  reported.  The  obstruction  is  rarely  encountered  in  the  jejunum 
or  upper  ileum,  and  shows  a  decided  predilection  for  the  cecum,  rectum, 
sigmoid,  ileocecal  valve,  and  the  lower  ileum,  and  has  been  encoun- 
tered less  often  in  other  segments  of  the  small  and  large  intestine,  viz. : 
Caird  (11  cases),  small  intestine  alone,  4;  ileocecal  region,  6;  ascending 
colon,  I ;  Fuch  (9  cases),  ileum,  2;  cecum,  7;  Erdheim,  ileum,  4;Trinkler, 
jejunum,  i;  Mikulicz,  jejunum,  2;  Balrous,  jejunum,  i;  Vohtz,  ileum, 
I;  Reach,  duodenum,  i;  ileum.  8;  Geosz,  ascending  colon,  multiple,  i; 
transverse  colon,  i;  Strehl  (cited  by  Reach),  ileum,  14;  hepatic  flex- 
ure, i;  Mummerys  100  collected  cases  (hyperplastic  tuberculosis), 
cecum,  48;  cecum  and  ascending  colon,  39;  cecum,  ascending  and  trans- 
verse colon,  3;  colon,  4;  sigmoid  flexure,  6. 

In  the  author's  cases  (14)  of  intestinal  tubercular  stenosis  the 
obstruction  occurred  as  follows:  ileum,  2;  ileocecal  region,  2;  trans- 
verse colon,  i;  descending  colon,  i;  sigmoid  flexure,  i;  rectum,  6; 
anus,  I. 

Tubercular  strictures  may  be  single  or  multiple,  but  the  former  are 
most  common  in  hyperplastic  tuberculosis  of  the  large  bowel,  and  the 
latter  in  the  enteric  and  enteroperitoneal  (ulcerative)  types  involving 
the  small  gut.  The  author  has  had  the  good  fortune  to  observe  both 
forms  of  tubercular  stricture,  and  in  one  of  his  cases  the  bowel  was 
obstructed  at  four  points. 

Busse  has  recorded  4  cases  of  multiple  tubercular  stenoses,  in  i  of 


250     TUBERCULAR   ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

which  there  were  ten  occlusions,  but  Maylard  has  gone  him  one  better 
and  records  a  case  where  there  were  eleven.  In  Vohtz's  case  the 
bowel  was  narrowed  12  inches  (30  cm.)  above  the  ileocecal  valve  and 
again  4I  feet  (130  cm.)  higher  up;  in  Reach's,  the  first  stricture  was  in 
the  duodenum  and  the  last  of  several  in  the  lower  ileum,  while  in  Geosz's 
multiple  stenoses  were  found  in  the  ascending  and  transverse  colons. 

Strictures  may  result  from  either  the  enteric  {ulcerative) ,  entero peri- 
toneal, hyperplastic,  or  fibrosclerotic  types  of  tuberculosis,  and  the 
character  of  the  occlusion  varies  greatly  in  different  cases,  for  the 
stenosis  is  annular  and  involves  but  a  short  segment  of  gut  in  the  first 
two  varieties  and  tube-like  in  the  last  named,  and  may  obstruct  any- 
where from  I  to  10  inches  (25  cm.)  or  more  of  the  gut.  In  the  former 
the  occlusion  is  produced  through  the  contraction  of  cicatricial  tissue 
frqm  healed  ulcers,  and  upon  digital  examination  the  rigid  ring-like 
annular  constriction  feels  like  a  syphilitic  stricture.  In  the  fibroscle- 
rotic or  stenosing  variety  the  intestinal  tunics  (especially  the  submucosa 
and  subserosa)  undergo  fibrosis,  and  contract  to  convert  a  considerable 
length  of  the  bowel  into  a  firm,  narrow,  resisting  tube  (the  so-called 
gas-pipe  intestine),  so  that  it  is  frequently  impossible  to  introduce  the 
finger  or  instrument  through  the  stricture  for  diagnostic  purposes. 
Stenoses  induced  by  hyperplastic  tuberculosis  occur  at  the  ileocecal 
region  in  about  85  per  cent.,  and  in  the  rectum  in  the  majority  of  other 
cases,  and  the  occlusion  does  not  result  from  the  contraction  of  cica- 
trices of  healed  ulcers  or  conversion  of  the  bowel  coats  into  fibrous 
tissue,  but  is  caused  by  an  encroachment  upon  the  gut  lumen  by  enor- 
mous round-celled  proliferation  in  the  gut  wall  and  peri-intestinal 
structures,  which  lead  to  the  formation  of  a  tumor  which  projects  into 
and  outside  the  cecum  or  involved  segment  of  intestine.  Sometimes 
the  stenosing  process  or  cell  proliferation  may  be  restricted  to  a  half- 
circle  of  the  bowel  or  extend  along  one  side  and  parallel  with  the  gut, 
under  which  circumstances  the  obstructions  are  present  as  crescen- 
tic-shaped  spurs  or  long  indurated  ridges. 

Usually  the  mucosa  remains  intact  below  a  tubercular  stricture, 
but  is  partially  or  completely  destroyed  at  and  above  the  constric- 
tion, owing  to  impaired  circulation,  trauma,  mixed  infection,  and  col- 
lections of  scybalae,  conditions  accompanied  by  the  discharge  of  blood, 
pus,  and  mucus  in  large  amounts.  Often  fecoliths  or  infected  material 
become  embedded  in  the  sores,  resulting  in  the  formation  of  sub- 
mucous or  perirectal  abscesses  and  fistulse  above  the  stenotic  level,  the 
pus  from  which  drains  downward  to  form  abscesses  or  fistulae  at  the  anal 
margin,  ischiorectal  fossa,  and  elsewhere,  that  may  be  simple  (strep- 
tococcic or  colon  bacilli)  or  tubercular. 

The  bowel  proximal  to  the  obstruction  is  usually  dilated,  owing 
to  the  tendency  of  gas  and  feces  to  collect  there,  and  its  walls  may  be 
either  thinned  or  thickened.  In  the  small  bowel  compensatory  mus- 
cular hypertrophy  sometimes  takes  place,  but  in  the  lower  bowel  the 
increased  thickness  of  the  gut  lumen  is  attributable  to  the  inflamma- 
tory changes  and  not  to  muscular  development. 


COMPLICATIONS    AND    SEQUELS    OF    INTF.STIXAL    TUBERCULOSIS      25 1 

The  caliber  of  the  stricture  may  be  moderate  in  size  or  so  small 
it  is  difficult  to  see  or  pass  with  an  instrument.  The  symptom-com- 
plex induced  by  the  intestinal  tubercular  stricture  depends  mainly 
upon  the  degree  of  obstruction  present.  When  the  block  is  slight  the 
patient  complains  of  tenesmus  and  constipation,  alternating  with  diar- 
rhea. If  the  obstruction  is  moderate,  there  is  a  backing-up  of  gas,  fecal 
impaction,  sensation  of  weight  and  fulness  in  the  bowel,  and  a  more 
frequent  desire  to  stool,  which  is  accompanied  by  straining  and  gives 
no  relief,  but  v/here  occlusion  is  almost  complete,  the  abdomen  remains 
distended,  there  is  an  incessant  desire  to  empty  the  bowel  and  an 
inability  to  do  so,  except  when,  through  the  aid  of  medication  or  ene- 
mata,  the  feces  are  rendered  fluid  and  expelled  in  small  quantities  and 
at  frequent  intervals  without  freeing  the  bowel  of  the  scybalse.  Fi- 
nally, when  the  stenosis  is  complete  the  usual  symptoms  of  acute  in- 
testinal obstruction  are  present,  and  will  continue  until  the  stricture  is 
enlarged,  excised,  or  an  artificial  anus  is  made  above  it. 

Strictures  of  the  lower  bowel  are  encountered  most  frequently  in 
the  rectum,  and  their  location  and  character  can  be  determined  by 
digital  examination,  but  when  situated  higher  in  the  rectum  and  sig- 
moid, they  are  diagnosed  by  carr^'ing  the  proctoscope  up  and  inspect- 
ing them.  No  attempt  should  be  made  to  force  the  instrument  or  a 
bougie  through  a  stricture  more  than  3  inches  above  the  anus  (the 
peritoneal  attachment),  because,  owing  to  the  ulcerated  condition  of 
the  gut,  it  is  liable  to  be  ruptured. 

Peritonitis  With  ,and  Without  Perforation.- — In  extensive  tuber- 
cular as  in  other  chronic  inflammatory'  and  ulcerative  lesions  of  the 
intestine,  the  peritoneum  may  be  specifically  or  other^vise  involved. 
In  such  cases  it  is  swollen,  reddened,  edematous,  and  dark  spots  appear 
upon  its  surface  at  the  sites  of  corresponding  lesions  in  the  mucosa. 
As  a  result  the  serosa  becomes  agglutinated  to  the  abdominal  pari- 
etes,  loops  of  intestine,  omentum,  and  other  organs  or  adjacent  struc- 
tures having  a  peritoneal  covering,  but  further  than  soreness  and 
interference  with  peristalsis  the  general  and  local  manifestations  con- 
sequent upon  peritoneal  involvement  are  unimportant. 

When  peritonitic  inflammation  results  from  the  caseation  of  dis- 
eased mesenteric  or  retroperitoneal  glands,  perforation  takes  place 
from  a  tubercular  or  mixed  infection  ulcer,  or  the  passage  of  tubercle 
bacilli  and  other  pathogenic  micro-organisms  through  the  diseased 
intestine,  the  infection  is  virulent,  widespread,  and  terminates  in 
general  or  circumscribed  peritonitis  often  complicated  by  abscess  and 
fistula,  and  the  patient  suffers  from  abdominal  pain,  distention,  ten- 
derness and  muscular  rigidity,  high  or  subnormal  temperature, 
nausea,  vomiting,  restlessness,  cold  extremities,  impaired  circulation, 
chilly  sensations,  blueness  of  the  skin,  constipation  or  aggravated 
diarrhea,  has  a  septic  skin,  leukocytosis,  and  the  usual  constitutional 
manifestations  of  sepsis. 

In  extreme  cases,  where  the  peritoneal  involvement  is  a  part  of 
general  miliary  tuberculosis,  the  omentum  and  gut  are  thickly  studded 


252     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

over  with  whitish  or  yellowish  caseating  tubercles.  As  a  rule,  miliary 
peritoneal  tuberculosis  does  not  respond  to  surgical  or  other  treatment 
because  it  is  part  of  a  general  infection  which  sooner  or  later  terminates 
fatally. 

Adhesions,  Kinks,  and  Ttvists. — Intestinal  tuberculosis,  particu- 
larly the  severer  types,  owing  to  peritoneal  inflammation  or  the  com- 
plicating abscess,  is  invariably  accompanied  by  the  formation  of  exu- 
dates or  organized  string,  fan,  or  band-like  massive  adhesions  which 
bind  the  gut  to  adjacent  structures,  having  a  peritoneal  covering 
which  materially  interferes  with  the  functionating  power  of  the  bowel. 
Where  peritonitis  has  been  general,  a  number  of  intestinal  loops 
may  be  found  glued  together  or  with  neighboring  or  distant  organs,  and 
form  narrow,  broad,  short,  or  long  adhesions. 

The  phenomena  induced  by  adhesions  depend  upon  their  num- 
ber, size,  and  relation  to  the  gut,  viz.:  bandular  obstruct  the  bowel 
by  pressing  upon  or  entwining  themselves  about  it,  or  fan-shaped 
(multiple)  angulate  or  twist  it  by  pulling  in  opposite  directions,  or 
when  one  end  of  an  adhesion  is  connected  to  one,  and  the  other  to 
another  segment  gut,  and  membranous  adhesions  by  compressing  a 
lengthy  piece  of  the  bowel  and  causing  intestinal  stasis. 

Kinking  of  the  bowel  sometimes  follows  the  healing  of  extensive 
tubercular  ulcers  and  the  formation  of  cicatricial  tissue. 

The  clinical  manifestations  induced  by  adhesions,  kinks,  and 
twists  depend  upon  the  extent  to  which  the  gut  is  affected,  and  when 
occlusion  is  slight  they  interfere  with  peristalsis,  cause  slight  gastro- 
intestinal distortions,  constipation  or  loose  movements,  localized 
tenderness,  and  occasional  enterospasm,  but  when  the  gut  lumen  is 
almost  or  quite  obliterated  by  them  the  abdomen  is  distended  with 
gas,  sensitive  and  rigid,  and  the  patient  suffers  from  obstipation  and 
recurring  fecal  impactions  or  persistent  diarrhea,  severe  abdominal 
pain  from  gas  accumulations  or  enterospasm.  nausea,  vomiting,  and 
the  usual  manifestations  of  acute  intestinal  obstruction,  or  necrosis 
when  pressure  sloughing  ensues. 

Abdominal  and  anorectal  abscesses  and  fistidcB  are  infrequent  com- 
plications of  bowel  tuberculosis,  and  may  be  caused  by  tubercle  bacilli 
or  mixed  infection  which  reaches  the  peritoneal  cavity  or  perirectal 
spaces  through  perforation  or  escape  of  pathogenic  micro-organisms 
through  the  non-resistant,  diseased  gut. 

Mixed  infection  abscesses  of  the  abdomen  induce  acute  and  pro- 
found pus  manifestations,  and  terminate  fatally  if  not  promptly  evacu- 
ated, while  tubercular  abscesses  are  inclined  to  chronicity  and  the  pus 
may  accumulate  in  enormous  quantities  without  creating  acute 
symptoms.  The  discharge  in  both  types  of  abscess  may  or  may  not 
contain  fecal  matter,  and  burrow  its  way  into  the  gut,  hollow  organs, 
or  follow  the  bowel  downward  to  open  into  or  near  the  rectum.  In 
children  abdominal  abscesses  usually  open  in  the  median  line  near  the 
navel  or  weakest  point  in  the  parietes.  In  adults  afflicted  with  ulcer- 
ative or  enteroperitoneal   tuberculosis  the  abscesses  may   discharge 


COMPLICATIONS    AND    SEQUEL.-E    OF    INTESTINAL    TUBERCULOSIS       253 

upon  the  abdominal  wall  at  any  point,  depending  upon  the  location  of 
intestinal  lesions,  hut  in  the  hyperplastic  type  the  discharge  finds  an 
outlet  in  the  right  iliac  fossa. 

Knteroperitoneal  tuberculosis  is  freciuenth'  accompanied  by  small 
or  considerable  sized  inter-  and  intramural  abscesses,  which  may 
penetrate  the  gut,  lift  the  mucosa  upward,  and  open  into  the  intes- 
tine below;  a  condition  e\idenced  b\-  the  finding  of  \ellow  pus  in  the 
stools. 

Abscesses  and  fistuhe  are  encountered  more  frequently  in  the  ano- 
rectal regions  than  higher  up,  because  here  the  protecting  influence  of 
the  peritoneum  and  peri-intestinal  adhesions  are  absent,  the  lesions 
are  more  extensixe,  and  the  l)owel  is  constantly  traumatized  by  the 
feces. 

Abscesses  here  are  designated  pelvirectal  when  they  originate  in 
the  pelvis,  perirectal  when  located  at  the  side  of  the  gut,  ischiorectal 
when  situated  in  the  ischiorectal  fossa,  marginal  when  at  the  muco- 
cutaneous border,  follicular  when  the  hair-follicles  become  infected, 
and  submucous  when  pus  collects  beneath  the  mucosa. 

Fistuhe  resulting  from  such  abscesses  are  named  according  to  the 
number,  location,  and  relation  of  their  openings,  viz.,  complete,  when 
there  is  one  opening  in  the  rectum  and  one  upon  the  surface  or  skin ; 
complete  internal,  when  both  are  in  the  rectum;  complete  external, 
when  both  are  upon  the  surface;  blind  external,  when  the  outlet  is 
through  the  skin;  blind  internal,  when  in  the  rectum;  rectovaginal, 
when  the  sinus  communicates  with  both  bowel  and  vagina;  recto- 
urethral  or  vesical,  when  it  extends  between  the  gut  and  the  urethra 
or  bladder;  horseshoe,  when  the  tract  encircles  the  rectum  and  opens 
into  it  and  upon  the  buttock  upon  either  side  of  the  anus;  and  complex, 
when  there  are  numerous  openings  in  the  bowel,  upon  the  surface, 
and  communications  between  the  rectum,  labia,  vagina,  urethra,  blad- 
der, or  pelvis. 

Complete  fistula  is  the  most  common  type,  and  in  this  and  other 
forms,  when  the  tract  connects  w-ith  the  rectum,  the  internal  opening 
is  located  in  the  posterior  median  line  |  inch  above  the  anus  in  90 
per  cent,  of  the  cases. 

From  the  standpoint  (jf  prognosis  there  are  three  types  of  ano- 
rectal fistuUi — the  tubercular,  difficult  to  heal  when  operated;  ordinary, 
occurring  in  individuals  devitalized  by  phthisis  which  require  a  con- 
siderable time;  and  simple,  which  are  easy  to  cure  because  there  are 
no  constitutional  disturbances  to  devitalize  the  patient. 

Generalization  of  the  Infection  {Miliary  Tuberculosis). — Generaliza- 
tion of  the  process  occasionally  occurs  secondary  to  intestinal  tuber- 
culosis elsewhere,  under  which  circumstances  miliary  tuliercles  are 
distributed  throughout  the  v.irious  organs.  In  such  cases  the  peri- 
toneum (Fig.  32)  and  omentum  present  a  speckled  appearance  pro- 
duced by  the  projecting,  smooth  or  caseating,  white  or  yellowish  tinted 
tubercles,  which  upon  the  mucous  and  skin  surfaces  of  the  anorectal 
region  appear  in  patches  and  sf)on  l)reak  down  (owing  to  the  trauma 


254     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

to  which  they  are  subjected),  to  form  superficial  cup-shaped  ulcers. 
These  lesions  may  extend  over  a  considerable  area  indi\-idually  or  by 
coalescence,  but  are  not  inclined  to  attack  the  deeper  structures  as  are 
other  forms  of  tuberculosis. 

The  prognosis  of  intestinal  miliary  tuberculosis  is  unfavorable  be- 
cause it  is  secondary  to  and  rarely  develops  until  after  the  disease  has 
become  well  established  elsewhere,  and  the  patient  is  debilitated  and 
unable  to  withstand  the  ravages  of  the  tuberculous  process. 

Carcinomatous  Grafting  Upon  the  Tubercular  Process. — Carcinoma 
frequently  complicates  intestinal  tuberculosis  or  follows  it  when  the 
ulcers  heal.  The  writer  believes  that  the  disease  here,  either  through 
its  traumatic  influence  induced  through  intestinal  activity  or  irrita- 
tion to  the  mucosa  consequent  upon  the  constant  passage  o\'er  it 
of  the  discharges,  is  a  predisposing  cause  of  intestinal  cancer.  He 
has  been  led  to  this  conclusion  through  obser\'ations  made  upon  2 
patients  colostomized  for  cancer,  in  whom  the  malignant  process 
had  rapidly  developed.  These  patients  gave  a  history  of  having  had 
chronic  colitis  and  diarrhea,  one  for  eighteen  months  and  the  other  for 
two  years  prior  to  cancerous  obstruction  in  the  sigmoid  and  rectum. 
Both  individuals  had  been  emaciated,  and  manifested  evidences  of 
tuberculosis  for  a  long  time  preceding  the  crisis  incited  by  the  growth. 
In  the  rectal  case,  tuberculous  appearing  ulcers  were  obser^-able  only 
above  and  below  the  neoplasm,  and  tubercle  bacilli  were  found  in 
scrapings  from  them.  In  the  other,  when  the  gut  was  withdrawn  for 
the  purpose  of  making  an  artificial  anus  to  relieve  the  cancerous  ob- 
struction in  the  sigmoid,  it  was  found  studded  with  tubercles,  and  the 
peritoneum  was  found  inflamed  and  thickened  in  the  vicinity  of  the 
ulcers;  on  the  mucous  membrane  in  the  rectal  case  tubercular  lesions 
were  plentiful  throughout,  and  there  was  a  large  raw  area  upon  the 
perineal  skin,  on  the  surface  of  which  were  numerous  fresh  and  case- 
ating  tubercles.     This  patient  was  also  suffering  from  phthisis. 

On  another  occasion,  where  a  number  of  rectal  and  abdominal 
glands  were  removed  with  a  carcinoma  at  the  rectosigmoidal  junc- 
ture, some  were  inflamed,  others  malignant,  and  the  remainder  tuber- 
culous and  in  a  state  of  caseation.  In  this  connection  it  is  well  to 
remember  that  tuberculosis  shows  a  predilection  for  the  cecum,  sig- 
moid, and  rectum,  the  most  common  sites  of  carcinomatous  degenera- 
tion. Crowder  has  also  reported  2  cases  of  carcinoma  associated  with 
intestinal  tuberculosis. 


CHAPTER   XXII 

TUBERCULAR   ENTERITIS,   COLITIS,  AND   ENTEROCOLITIS 
(INTESTINAL  TUBERCULOSIS),  DIARRHEA  IN  (Continued) 

DIAGNOSIS 

General  Remarks. — It  is  frcquenily  difficult  or  impossible  (except 
by  operation  or  autopsy)  to  distinguish  tubercular  lesions  from  those 
caused  by  catarrhal  and  infectious  diseases  of  the  bowel,  because  the 
intestinal  and  other  manifestations  induced  by  them  are  similar,  and, 
further,  because  tubercular  infection  may  complicate  a  simple  or 
infectious  enterocolitis.  It  may  at  times  require  prolonged  obser^'a- 
tion  and  astute  diagnostic  ability  to  determine  the  type  of  tubercu- 
lous lesions  one  has  to  deal  with,  irrespective  of  whether  they  involve 
the  small  or  large  intestine,  or  both,  owing  to  the  fact  that  in  all  varie- 
ties there  may  be  complicating  foci  in  other  organs,  the  patient  shows 
constitutional  characteristics  of  the  disease,  gastric  and  intestinal 
disturbances  are  present;  there  is  no  difference  in  so  far  as  a  tuberculin 
or  diazo  urinar\'  reaction  is  concerned,  and  further,  because  the  patient 
may  be  affected  simultaneously  with  different  types  of  intestinal  tuber- 
culosis in  the  same  or  different  segments  of  the  bowel,  which  would 
blend  the  manifestations  and  confuse  the  diagnosis. 

In  the  majority  of  advanced  cases,  however,  the  symptoms  of  the 
different  types  of  infection  are  sufficiently  typic  to  enable  the  clini- 
cian, with  the  aid  of  the  microscope,  to  distinguish  between  them,  and 
determine  if  another  affection  is  associated  with  the  tuberculosis. 

The  author  carefully  examines  for  intestinal  tuberculosis  all  per- 
sons, young  or  old,  coming  to  him  who  are  emaciated,  have  a  sallow 
complexion,  suffer  from  digestive  disturbances  or  diarrhea,  pass  pus, 
blood,  or  mucus,  singly  or  together,  and  have  a  cough  or  give  a  family 
histon,-  of  phthisis. 

Diarrhea  is  the  pathognomonic  s\-mptom  of  bowel  tuberculosis, 
but  occasionally  this  class  of  patients  suffer  from  constipation  or  obsti- 
pation, alternating  with  diarrhea,  when  the  bowel  is  ulcerated  or 
blocked  by  a  tubercular  tumor. 

Usually,  tubercular  lesions  of  all  kinds  and  wherever  located  induce 
a  slight  or  aggravated  diarrhea,  but,  as  a  rule,  the  movements  are 
more  frequent  and  fluid  when  the  lesions  are  located  in  the  lower 
sigmoid  and  rectum  than  when  situated  in  the  small  intestine  and 
colon,  because  the  disease  is  always  more  aggravated  in  these  regions. 

Diarrhea,  in  the  main,  results  from  irritation  to  exposed  ner\e- 
filaments,  which  cause  hyperglandular  secretion,  frequent  and  pro- 
longed peristaltic  contractions  and  deficient  colonic  absorption  con- 

255 


256     TUBERCULAR    ENTERITIS.    COLITIS.    ENTEROCOLITIS,    DIARRHEA    IN 

sequent  upon  the  inflammatory  and  ulcerative  state  of  the  mucosa, 
factors  which,  in  working  together,  increase  the  watery  constituent 
of  the  intestinal  contents  and  cause  frequent  evacuations. 

The  number  of  movements,  amount  of  pus,  blood,  and  mucus  dis- 
charged and  degree  of  suftering  induced  by  intestinal  tuberculosis 
corresponds  closeh"  with  the  extent  to  which  the  bowel  is  denuded 
of  its  mucosa. 

The  author  will  now  outline  the  chief  points  of  differentiation 
between  the  different  types  of  tuberculosis,  and  this  disease  and  other 
affections  which  mimic  it.  following  which  he  will  discuss  the  compli- 
cations of  intestinal  tuberculosis. 

Diagnosis  of  Enteric  (Ulcerative)  and  Enteroperitoneal  Tubercu- 
losis.— In  most  instances  it  is  comparatively  easy  to  differentiate 
between  hyperplastic  and  other  forms  of  intestinal  tuberculosis,  but 
between  the  ulcerative  and  enteroperitoneal  types  of  the  disease  it  is 
always  difficult,  because  in  both  constitutional  manifestations  are 
present,  gastro-intestinal  disturbances  are  about  the  same,  and  both 
are  accompanied  by  discharge  of  mucus,  blood,  and  pus.  The  most 
significant  differential  feature  between  them  is  that  the  symptoms  of 
enteroperitoneal  become  aggravated  very  quickly,  are  more  difhcult 
to  control,  and  the  disease  terminates  fatally  sooner  and  more  often 
than  enteric  tuberculosis.  In  the  former  (enteroperitoneal)  the  entire 
wall  becomes  involved  early  by  the  inflammatory-  and  ulcerative  proc- 
esses and  the  disease  extends  rapidly  within  and  without  the  bowel, 
owing  to  caseation  and  necrotic  changes  and  extension  of  the  disease 
through  the  coalescing  of  formed  ulcers  and  mixed  infection.  Out- 
wardly, evidences  of  the  disease  are  shown  in  the  uneven,  congested 
peritoneum  and  exudates  and  adhesions  which  are  largely  responsible 
for  the  pain  and  tenderness  elicited  by  pressure.  Sometimes  through 
the  lymphatics  perforation  or  infection  takes  place,  resulting  in  cir- 
cumscribed peritonitis,  matting  together  of  the  intestines  and  adja- 
cent organs,  and  the  formation  of  an  ordinary  or  pyostercoral  abscess, 
which  becomes  encysted  or  discharges  through  the  gut,  or  finds  an 
outlet  through  the  abdominal  wall. 

The  general  manifestations  of  enteroperitoneal  tuberculosis  are 
more  profound  because  of  extensive  miliar\^  deposits  observable 
in  the  peritoneum  and  bowel,  and  its  frequent  association  with  tuber- 
cular lesions  in  other  organs,  particularly  the  lungs,  from  whence  auto- 
inoculation  takes  place  by  way  of  the  blood  when  the  phthisic  lesions 
involve  a  vessel,  or  by  swallowing  infected  sputum. 

Owing  to  the  through-and-throiii^h  diseased  condition  of  the  gut  wall, 
it  is  very  tender  upon  pressure,  and  attacks  of  enterospasm  or  cramps 
occur  more  frequently  and  severely  in  enteroperitoneal  than  ulcerative 
tuberculosis  where  the  mucosa  is  chiefly  in\olved.  Again,  obstruct- 
ive manifestations  are  observable  less  often  in  the  former  than  the 
latter  because  the  disease  early  terminates  fatalh'.  or  the  ulcers  do  not 
heal  and  form  strictures,  as  the  therapeutic  measures  directed  against 
them  do  not  reach  the  diseased  middle  and  outer  tunics. 


DIAGNOSIS    OF    ENTERIC    AND    ENTEROPERITONEAL    TUBERCULOSIS     257 

Pus,  blood,  and  mucus  are  present  in  slight  or  considerable  amounts 
in  both  t>pes  of  tuberculosis,  and  in  catarrhal,  syphilitic,  dysenteric, 
gonorrheal,  or  diphtheric  colitis.  Consequently,  it  is  impossible  to 
differentiate  between  ulceratixe  or  enteroperitoneal  tuberculosis  by 
examining  the  discharges,  but  a  careful  microscopic  examination  of 
the  stools  enables  one  to  diagnose  tubercular  from  other  types  of  colitis 
when  the  bacilli  are  found.  Tubercle  bacilli  are  rarely  present,  or, 
if  so,  they  are  seldom  found  by  examining  the  stools,  particularly 
when  the  lesions  are  located  in  the  small  bowel,  but  the  author  has 
occasionally  been  able  to  detect  them  in  tuberculosis  of  the  colon  and 
rectum,  but  more  often  in  ilic  scrapings  of  ulcers  than  in  the  dis- 
charges or  feces. 

The  best  way  to  obtain  material  for  examination  when  the  dis- 
ease involves  the  rectum  or  sigmoid  is  to  introduce  a  proctosigmoid- 
oscope,  expose  raw  areas  and  curet  their  bases  and  edges,  reserving 
the  removed  debris  for  examination,  for  bacilli  are  found  more  fre- 
quently and  with  less  trouble  in  infected  tissue  in  the  discharges  or 
feces  than  in  the  usual  method  where  the  evacuated  discharges  are 
examined. 

A  certain  amount  of  information  can  be  obtained  by  examining 
the  fragments  of  tissue  found  in  the  stools  of  tuberculous  patients  to 
see  whether  they  result  from  the  necrotic  tissue  or  undigested  meat 
remnants. 

Too  much  importance  is  placed  upon  the  finding  of  tubercle  bacilli, 
even  when  present,  because  they  may  be  found  in  the  feces  of  indi- 
viduals who  have  phthisis  alone  or  both  lung  and  intestinal  infection. 
Klose  was  able  to  demonstrate  tubercle  bacilli  in  the  evacuations  of 
47  out  of  60  consumptives  in  whom  there  was  no  evidence  of  intestinal 
involvement. 

Chvostek  and  Stromayer  place  considerable  importance  upon  a 
urinary  examination  in  persons  suspected  of  having  intestinal  tuber- 
culosis, because,  after  administering  peptone,  they  have  been  able  to 
demonstrate  albuminuria.  From  the  author's  experience  he  is  in- 
clined to  place  more  reliance  upon  Ehrlich's  diazo-reaction  than  the 
finding  of  albumin  under  the  circumstances  enumerated. 

Much  more  importance  is  to  be  placed  upon  a  positive  tuberculin 
reaction  test  (particularly  in  children),  as  indicated  by  a  marked  rise 
in  temperature,  nausea,  restlessness,  muscular  pains,  and  other  sub- 
jective symptoms,  which,  when  obtained,  points  strongly  toward  the 
tubercular  nature  of  the  disease.  Tuberculin  may  be  satisfactorily 
emplo\ed  in  the  form  of  an  intramuscular  injection,  gr.  yV  to  yV 
(0.004-0.006),  when  but  a  single  dose  is  given,  or  as  practised  by 
Lowenstein  and  Kaufmann,  who  administer  it  in  doses  of  gr.  3V 
(0.002),  repeating  about  every  four  days  until  three  or  four  injections 
have  been  made,  mainteiining  that  each  dose  prepares  the  patient  for 
a  more  favorable  reaction.  When  the  above  is  ineffecti\e,  the  dosage, 
beginning  at  gr.  3V  (0.002),  is  increased  to  gr.  jV  (0.005),  or  even  gr.  ^ 
(o.oi),  until  the  reaction  is  obtained. 


258     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

Preferably  the  injections  should  be  given  in  the  evening,  and  the 
temperature  should  be  taken  every  tew  hours,  and  when  it  rises  5 
degrees  Koch  considers  the  reaction  positive. 

The  part  played  by  the  opsonic  index  is  not  so  valuable  in  diagno- 
sis as  it  is  in  treatment,  yet  it  deserves  to  be  mentioned.  It  is  unre- 
liable here  because  the  same  indications  are  present  in  tuberculosis 
of  the  lung  as  of  the  intestines,  and  when  the  disease  attacks  several 
organs  the  opsonic  index  does  not  help  one  in  finding  out  which  par- 
ticular organ  is  involved  in  the  tuberculous  process. 

French,  mentioned  by  May  lard,  says:  "In  the  case  of  tubercle 
bacilli  the  opsonic  indices  of  a  series  of  healthy  individuals  may  vary 
from  0.8  to  1.2  or  thereabouts,  but  in  tuberculous  patients  the  index 
may  be  as  low  as  0.3  or  as  high  as  i  .8,  or  even  higher.  The  estimation, 
therefore,  may  be  of  considerable  diagnostic  value  in  cases  where  there 
is  doubt  as  to  whether  the  lesion  is  tuberculous  or  not.  If  the  index 
is  below  0.7  or  above  1.3  the  argument  w'ill  be  in  favor  of  tubercle, 
the  resisting  power  of  the  patient  being  low  in  the  first  case,  high  in 
the  second.  ...  It  has  been  found  that  after  injecting  -roW  nig.  of 
tuberculin  R.  into  a  healthy  man  the  opsonic  index  falls  slightly  for 
about  two  days,  then  rises  to  slightly  above  normal,  and  then  returns 
to  what  it  was  originally.  A  similar  injection  into  a  tuberculous 
patient  is  followed  by  a  considerable  fall  in  the  opsonic  index,  the 
latter  remaining  below  what  it  originally  was  for  a  week  or  more,  by 
which  time  it  has  begun  to  rise  again  above  what  it  was  before.  The 
initial  fall  after  the  injection  is  called  the  negative  phase.  This  nega- 
tive phase  is  quite  short  in  healthy  people,  long  in  tuberculous  sub- 
jects, so  that  we  have  here  an  additional  means  of  diagnosis." 

An  examination  of  the  hlood  is  sometimes  useful  because  leukocyto- 
sis is  high  in  malignant  ulceration  of  the  intestine,  and  slight  or  absent 
in  tuberculosis  of  the  bowel.  The  author  does  not  underestimate  the 
value  of  tuberculin,  peptonitic  and  diazo  reactions,  and  hlood  analysis, 
but  places  greater  reliance  upon  the  subjective  and  objective  symptoms 
of  intestinal  tuberculosis,  particularly  when  tubercle  bacilli  are  found 
in  the  stools. 

Thus  far  the  differential  diagnosis  of  ulcerative  and  cnteroperi- 
toneal  tuberculosis  has  been  discussed  in  a  general  w^ay,  and  it  now 
remains  to  call  attention  to  the  principal  points  of  differentiation 
between  them  and  neoplastic  tuberculosis,  and  a  few  of  the  more 
common  affections  which  have  been  confused  with  them. 

The  manifestations  of  enteric,  enteroperitoneal,  and  neoplastic 
tuberculosis  closely  resemble  each  other  in  the  incipient  stage  because 
of  the  accompanying  gastro-intestinal  disturbances,  but  when  the 
disease  has  become  fairly  well  developed  the  diagnostic  picture  of 
hyperplastic  tuberculosis  varies  greatly  from  that  of  the  other  forms. 
Briefly  stated,  neoplastic  differs  from  other  types  of  intestinal  tuber- 
culosis in  that  it  occurs  in  early  adult  life,  develops  more  slowly, 
causes  less  emaciation,  diarrhea  is  less  aggravated,  obstruction  more 
marked,  and  there  is  a  characteristic  right-sided  tenderness,  fulness, 


DIAGNOSIS    OF    ENTKRIC    AND    ENTEROPICRITONEAL    TUBERCULOSIS     259 

pain,  and  tumor,  comparatively  little  or  no  pus,  blood,  and  mucus, 
and  postoperative  results  are  \ery  much  better. 

So-called  fibroscU'i'otir  tuberculosis  (which  the  author  believes  to 
l)e  a  variety  of  the  neoplastic  type)  often  causes  diarrhea  and  other 
manifestations  resembling  ulcerative  tuberculosis,  but  is  distinguished 
from  them  by  its  chronicity,  hard,  firm,  tube-like  feel  of  the  intestine, 
the  slight  amount  of  pus,  blood,  and  mucus  in  the  stools,  and  absence 
of  ulceration  prior  to  the  stricture  formation. 

Amyloid  degencnition  sometimes  resembles  tuberculosis  of  the 
intestine,  and  the  diagnosis  must  be  arrived  at  by  exclusion.  This 
form  of  degeneration  is  encountered  in  the  small,  and  tuberculosis 
occurs  in  the  large,  intestine;  the  mucosa  of  the  former  is  pale  and 
waxy  and  villi  are  missing,  while  in  the  latter  it  is  often  red,  swollen 
and  edematous,  and  the  villi  are  distinguishable  except  at  ulcerated 
points.  In  amyloidosis  the  diagnosis  is  based  principally  upon  the 
iodin  reaction,  which,  when  applied  to  diseased  areas,  turns  them  a 
brownish-red  color,  the  hue  of  which  is  converted  to  violet  by  the 
addition  of  sulphuric  acid,  and  a  pink  color  when  methyl-violet  is 
employed,  but  the  diagnosis  is  not  always  possible  during  the  patient's 
lifetime. 

Actinomycosis  in  many  particulars  resembles  hyperplastic,  but 
has  been  mistaken  for  both  enteric  (ulcerative)  and  enteroperitoneal, 
tuberculosis.  This  condition  is  accompanied  by  gastralgia  and  enter- 
algia,  and  more  frequently  induces  constipation  than  diarrhea,  at 
least  during  the  earlier  stages.  The  mucosa  presents  an  uneven  sur- 
face because  of  nodular  swellings  which  in  no  way  resemble  tubercles, 
but  when  these  granulomatous  deposits  break  down  they  form  lesions 
which  look  like  tubercular  ulcers,  especially  wdien  chronic,  owing  to 
the  part  played  by  mixed  infection  in  both.  In  the  later  stages  of  the 
disease  there  is  no  excuse  for  confusing  actinomycosis  with  ulcerative 
tuberculosis  because  it  is  accompanied  in  rapid  succession  by  the 
iormation  of  a  tumor  in  the  cecal  region,  painful  infiltration  of  the 
abdominal  wall,  and  the  opening  of  sinuses  through  it  (especially  low 
down),  from  which  exudes  a  viscid  discharge  containing  debris  and 
t\pic  yellow  sulphur-like  granules,  which,  under  the  microscope,  show 
the  fungus.  In  the  absence  of  sinuses  a  positive  diagnosis  is  impos- 
sible, except  w^hen  the  fungus  is  revealed  by  urinary  or  fecal  exami- 
nation. 

Syphilitic  can  be  differentiated  from  tubercular  disease  of  the 
intestine  by  obtaining  a  history  of  chancre,  observing  specific  lesions 
elsewhere,  finding  the  spirochetes,  obtaining  a  positive  Wassermann 
reaction,  impro\-ing  the  patient's  condition  by  the  administration  of 
mercury  and  potassium,  arsenic  preparations,  or  saKarsan  in  the 
absence  of  a  tuberculin  reaction. 

Typhoid  fever  is  easily  differentiated  because  of  variance  in  the 
symptom-complex  and  positive  Widal  reaction. 

Gastric  and  duodenal  ulcers  are  occasionally  mistaken  for  tuber- 
cular lesions  of  the  intestine,  but  this  is  not  likely  to  occur  when  due 


26o     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

care  is  taken,  because  the  constitutional  manifestations  of  tuberculo- 
sis are  absent,  and  when  the  lesions  are  in  the  stomach  or  duodenum 
the  patient  sufTers  more  acutely  from  pain  in  these  regions,  vomiting, 
inability  to  retain  food,  hematemesis  and  agony  shortly  following 
eating  because  of  the  pouring  out  of  the  hydrochloric  acid;  and,  fur- 
ther, for  the  reason  that  the  stools  contain  no  pus,  blood,  and  little 
mucus,  all  of  which  are  found  in  intestinal  tuberculosis. 

Dysentery  is  more  often  confused  with  intestinal  ulcerative  tuber- 
culosis than  any  other  affection.  The  former  very  rarely  attacks  the 
small  intestine,  being  confined  principally  to  the  colon  and,  more  par- 
ticularly, the  sigmoid  flexure  and  upper  rectum,  where  characteristic 
stellate  ulcers  can  be  observed  through  the  sigmoidoscope.  Diarrhea, 
mucus,  and  pus  occur  with  equal  frequency  in  both  affections,  and 
vary  according  to  the  duration  and  extent  of  the  disease,  but  bleeding 
and  tenesmus  are  more  pronounced  in  dysenteric  ulceration,  and  the 
pain  which  accompanies  this  condition  is  sharper  and  more  centrally 
located  than  in  tuberculosis.  The  finding  of  entamebai  or  bacilli  of 
Shiga,  Flexner,  or  Hiss  is  necessary  to  complete  the  diagnosis. 

Dyspeptic  enteritis,  which  may  be  mistaken  for  or  complicate  all 
types  of  intestinal  tuberculosis,  is  caused  by  gastrogenic  disturb- 
ances such  as  hypo-  and  hyperchlorhydria,  under  which  circumstances 
there  is  usually  interference  with  the  biliary  and  pancreatic  secretions. 
Here  the  stools  are  not  increased  in  number,  but  contain  glairy  mucus 
and  induce  more  or  less  tenesmus.  Later,  when  both  the  stomach  and 
intestine  are  involved  and  the  secretions  are  augmented,  the  move- 
ments are  more  numerous,  soft,  offensive,  and  foamy,  but  differ  from 
ulcerative  tubercular  enteritis  in  that  the  diarrhea  alternates  with 
constipation. 

Chronic  enteritis  resulting  from  ptomain-poisoning  somewhat 
resembles  intestinal  tuberculosis,  but  the  history  of  a  sudden  and 
violent  onset,  very  great  pain,  nausea,  vomiting,  collapse,  and  exhaust- 
ing diarrhea  go  far  toward  differentiating  this  condition.  In  these 
violently  toxic  diarrheas  the  number  of  polynuclear  cells  is  consider- 
ably increased  (Loepcr),  and  the  absence  of  amebse  and  tubercle 
bacilli  in  the  stools  helps  to  confirm  the  diagnosis  of  ptomain-poisoning. 

Diagnosis  of  Hyperplastic  (Ileocecal)  Tuberculosis. — Hyperplastic 
tuberculosis,  irrespective  of  whether  it  is  located  in  the  small  or  large 
intestine,  is  never  diagnosed  in  the  earlier  stages  except  by  chance, 
because  the  gastro-intestinal  derangements  excited  by  the  infiltrating 
process,  which  is  unimportant  at  this  time,  are  but  slight,  and  differ 
but  little  if  at  all  from  other  and  more  common  intestinal  ailments. 
Nor  does  the  author  believe  it  possible  to  make  a  diagnosis  of  hyper- 
plastic involvement  of  the  small  intestine  in  the  vast  majority  of 
cases  in  any  stage  of  the  disease,  because  the  neoplastic  thickening  is 
less  marked  here  than  in  the  colon,  which  makes  it  almost  or  quite 
impossible  for  the  clinician  to  detect  the  swelling  by  palpation  or  other 
means,  and,  further,  since  if  the  tumor  could  be  discovered  it  could  not 
be  differentiated  with  certainty  from  other  neoplasms  causing  obstruc- 


DIAGNOSIS    OF    HYPERPLASTIC    (iLKOCECAL)    TUBERCULOSIS        26 1 

tion.  P2ven  when  the  disease  has  progressed  to  a  considerable  degree, 
and  is  located  at  its  usual  site  in  the  ileocecal  region,  neoplastic  tuber- 
culosis is  rarely  suspected,  because  of  the  infrequency  with  which  it 
occurs  and  the  fact  that  the  consequent  disturbance  to  the  digestive 
apparatus,  right-sided  swelling,  tenderness  and  pain,  loss  of  weight, 
integumentar>'  manifestations  of  auto-intoxication,  and  the  occasional 
presence  of  mucus  in  the  stools,  may  all  or  in  part  be  produced  by  dis- 
turbances of  the  stomach  and  bowel,  appendicitis,  circumscribed  peri- 
tonitis, tumors,  or  disease  wiiliin  ilie  abdomen  or  pelvis. 

It  is  not  so  difficult,  however,  to  recognize  neoplastic  tubercular 
tumors  of  the  large  bowel  and,  particularly,  of  the  cecum,  the  seat  of 
their  predileciitjn.  when  the  disease  has  fully  de\eloped,  and  one  con- 
siders the  history  of  the  case,  the  symptoms  as  outlined  above,  makes 
a  careful  examination  of  the  abdomen,  and  bears  in  mind  the  diagnostic 
peculiarities  of  the  disease  included  in  the  following  description : 

One  is  justified  in  suspecting  hyperplastic  tuberculosis  in  indi\id- 
uals  between  twenty  and  forty  who  give  a  history  of  or  suffer  from 
phthisis,  are  chronically  ill,  have  a  poor  appetite,  indigestion,  become 
emaciated  slowly,  run  an  occasional  degree  of  temperature,  complain 
of  diarrhea  or  frequent  movements  alternating  with  constipation, 
tenderness  upon  pressure,  pain  and  fulness  in  the  right  iliac  fossa. 
Later,  when  the  tumor  has  assumed  fair  proportions,  if  cancer  be 
excluded  according  to  the  method  of  differentiation  outlined  below, 
there  is  no  reason  why  a  correct  diagnosis  should  not  be  made  in  the 
vast  majority  of  instances.  The  neoplasm  is  recognized  by  its  pred- 
ilection for  the  cecum,  limitation  to  the  ileocecal  region,  slow  growth, 
bulging  appearance,  firmness,  large  size,  oval  shape,  fixation,  fibro- 
adipose  capsule,  sensitiveness  on  pressure,  dulness  on  percussion,  ex- 
tensive inxolvement  of  the  mesenteric  and  retroperitoneal  glands, 
presence  of  polypoid  and  papillomatous  growths  in  the  affected  gut, 
partial  or  complete  obstruction  induced,  crater-like  ulcers  when  the 
neoplasm  degenerates,  pericecal  adhesions,  circumscribed  peritonitis, 
and  occasionally  pyostercoral  abscess  and  fistula  when  perforation 
takes  place. 

The  papillomatous  vegetations  mentioned  are  pathognomonic  of 
the  disease,  and  are  encountered  ver>'  much  more  often  in  this  than 
other  types  of  the  disease.  Peristaltic  movements  of  the  intestine 
can  occasionally  be  felt  and  seen  during  the  attacks  and  when  the 
patient  suffers  from  cramps,  but  this  symptom  is  less  frequent  and 
severe  in  neoplastic  than  it  is  in  either  the  ulcerative  or  enteroperitoneal 
type  of  tuberculosis.  The  manifestations  of  obstruction  are  always 
present,  naturally  vary  according  to  the  degree  of  stenosis,  but  dis- 
tention, gurgling,  and  splashing  sounds  are  at  inter\-als  present  in 
nearly  all  cases,  owing  to  the  backing  up  of  gas  and  fluid  feces,  and, 
as  a  result,  a  tympanitic  is  substituted  for  a  dull  percussion  note. 

In  those  exceptional  cases  where  ulceration  early  complicates  tumor 
formation,  and  the  process  reaches  the  peritoneum,  hyperplastic 
closely  resembles  enteroperitoneal  tuberculosis  until  the  true  state  of 


262      TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS.    DIARRHEA    IN 

affairs  is  revealed  by  the  manifestation  of  a  tumor  in  the  right  ihac 
fossa. 

In  this  form  of  the  disease  the  mucosa  is  frequently  not  disturbed, 
and  when  it  is,  ulceration  occurs  in  the  later  stages  of  the  disease  after 
the  circulation  has  become  impaired  by  the  neoplasm,  when,  through 
the  necrotic  processes,  extensive  deep  ulcers  are  formed  which  in  no 
way  resemble  the  superficial  types  seen  in  the  other  varieties  of  intes- 
tinal tuberculosis.  This  goes  far  to  explain  why  it  is  that  individuals 
afflicted  with  this  form  of  tuberculosis  do  not  suffer  so  early,  fre- 
quently, or  so  severely  as  persons  having  the  ulcerative  or  entero- 
peritoneal  forms  of  tuberculosis,  where  numerous  lesions  are  found  in 
the  mucosa  almost  from  the  incipiency  of  the  disease.  Consequently, 
pus,  blood,  and  mucus  in  the  stool  occur  less  often  and  in  smaller 
amount  in  the  neoplastic  than  in  the  varieties  of  the  disease  just  men- 
tioned, and  the  odor  of  the  stools  is  less  fetid,  owing  to  the  fact  that  the 
discharge,  mixed  infection,  and  the  accompanying  putrefaction  is 
correspondingly  less. 

Differential  Diagnosis  of  Hyperplastic  (Ileocecal)  Tuberculosis. — 
It  is  always  extremely  difficult  if  not  impossible  to  make  a  diagnosis 
of  hyperplastic  tuberculosis  when  the  disease  is  situated  in  the  small 
intestine,  except  by  exploratory  laparotomy  or  autopsy,  and  then,  in 
many  instances,  not  without  the  aid  of  the  microscope,  since  here  the 
symptoms  resemble  enteritis  or  obstruction,  and  the  pathologic  changes 
in  the  gut  cannot  be  made  out  owing  to  the  smallness  of  the  tumor. 

It  cannot  be  denied  that  ileocecal  tubercular  neoplasms  have  often 
been  mistaken  for  other  diseases  and  growths,  particularly  cancer, 
but  in  the  light  of  our  present  knowledge  concerning  this  affection 
mistaken  diagnoses  should  be  extremely  rare,  because  these  enlarge- 
ments have  the  peculiarities  and  symptoms  previously  noted,  which, 
when  carefully  studied,  should  distinguish  them  from  other  ailments. 

Hyperplastic  tubercular  formations  of  the  intestine  have  been 
most  frequently  mistaken  for  carcinoma,  appendicitis,  perityphlitis, 
chronic  adenitis,  actinomycosis,  fecal  impaction,  gummata,  psoas 
abscess,  and  massive  adhesions.  Naturally,  it  is  confused  most  fre- 
quently with  carcinoma  because  of  its  firm,  tumor-like  consistency', 
and  the  fact  that  cancer  is  so  frequently  encountered  at  the  cecum 
and  in  the  rectum,  the  most  common  sites  of  hyperplastic  tuberculo- 
sis, and,  further,  because  the  profession  has  not  been  well  acquainted 
with  this  disease  nor  sufficiently  watchful  for  the  neoplastic  type  of 
the  trouble.  Many  patients  are  unnecessarily  permitted  to  die  yearly 
by  general  surgeons  who  mistake  neoplastic  intestinal  tumors  for  in- 
operable cancers,  and  refuse  them  a  radical  operation  when  the  growth 
could  be  enucleated  with  comparative  safety  and  without  leaving 
annoying  sequehc. 

In  order  to  avoid  unnecessary  detail  in  describing  the  character- 
istics of  carcinoma  and  neoplastic  tuberculosis  the  author  has  con- 
densed the  differential  data  in  the  accompanying  table,  which  con- 
tains the  diagnostic  characteristics  of  these  ailments: 


DIFFERENTIAL    DIAGNOSIS    OF    HYPERPLASTIC    TUBERCULOSIS      263 


DIFFERENTIAL  DIAGNOSIS   BETWEEN   ILEOCECAL   HYPERPLASTIC 
TUBERCULOSIS   AND    CANCER 

HYPERPLASTIC  TUBERCULOSIS  OF  THE  CECUM.  CARCINOMA    OF    THE    RECTUM. 

Age 
Twenty  to  forty  (principally  third  decade).       Forty  to  sixty.     Childhood  very  rare. 


Childhood  not  uncommon. 
Slow. 

Two  to  three  years. 

Usually  slight. 

Absent. 

Slow  and  slight. 

Early  and  marked. 

Common. 

Late  and  partial. 

More  or  less. 

Present. 

Marked. 

Cecum  drawn  upward. 

Always  the  cecal  region. 

Fixed. 
Usually. 
Occasionally. 
Very  rare. 
Occasionally. 


Ousel  and  Progress 
Rapid. 

Duration 

Four  to  ten  months. 

Pain 

More  frequent  and  marked. 

Cachexia 

Present. 

Emacialion 

Rapid  and  pronounced. 

Indigestion 

Late  manifestation. 

Fever 

Uncommon. 

Obstruction 

r^arly  and  marked. 

Abdominal  Tenderness 
Unusual. 

Gurgling  and  Splashing 
Rarely  so. 

Peristalsis 

Slight. 

Position 

Cecum  normal  position. 

Location 

Anywhere  in  the  colon,  particularly  at  the 
flexures. 

Mobility 

Slightly  movable. 

Intestine  Palpable 
Rarely. 

Abscess  and  Fistula 

\'ery  rarely. 

Hemorrhage 

More  frequent. 

Blood  and  Pus  in  Stools 
Always. 


264      TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 


DIFFERENTL\L   DL\GNOSIS    BETWEEN  ILEOCECAL  HYPERPLASTIC 
TUBERCULOSIS   AND    CANCER    {Contimi(d) 

HYPERPLASTIC   TUBERCULOSIS  OF  THE  CECUM.  CARCINOMA    OF    THE    RECTUM. 

Bacilli  in  Stools 
Absent. 


Tubercular  occasionally. 

Slight. 

Practically  always. 

Usually  positive. 

Leukopenia  frequent. 

Frequently  present. 

Frequent  (lungs,  etc.). 

Thickened. 

Always  extensively  involved. 

Broad,  oval,  and  smooth. 

Subserosa  especially  affected. 

Rarely  breaks  down. 

Giant  cells,  tubercles,  baciUi. 


Fetid  Odor  to  Stools 

Characteristically  foul. 

Peritonitis  (Circumscribed) 

Occasionally. 

Tuberculin  Reaction 
Absent. 

Leukocytosis 

Moderate. 

EJirlich's  Diazo-reaction 
Absent. 

Involvement  of  Other  Organs 

Infrequent  (hver). 

Adjacent  Gut 

Normal. 

Mesentery  and  Peritoneum 

Sometimes  and  less  extensively. 

Tumor  Characteristics 

More  nodular  and  firm. 

Bo-d'el  Wall 

Submucosa  involved. 

Retrogressive  Changes 

Degenerates  and  forms  crater-like  ulcers. 

Microscopically 

Characteristic  tumor  cells. 


Hyperplastic  ileocecal  tuberculosis,  more  particularly  in  its  earlier 
stages,  has  been  mistaken  for  chronic  appendicitis  because  of  its 
location  and  the  corresponding  tenderness,  pain,  and  infiltration 
which,  to  a  varying  degree,  are  encountered  in  both.  Later,  how- 
ever, when  the  tubercular  process  has  become  neoplastic  in  character, 
one  is  not  liable  to  be  deceived  and  mistake  it  for  appendiceal  or 
perityphlitic  inflammation  because  the  tumor  induces  obstruction, 
can  be  seen  or  felt,  the  more  acute  manifestations  of  the  latter  are  not 
noticeable,  and  since  the  attacks  of  appendicitis  and  perityphlitis 
are  more  intermittent. 

Neoplastic  tuberculosis  has  been  diagnosed  in  a  few  instances  as 
enlarged  massed  glands  where  the  nodes  have  become  inflamed 
or  specifically  diseased,  surrounded  and  fixed  by  exudates  and 
adhesions,  or  degenerated,  forming  abscesses  and  fistulas.     Such  a  mis- 


PRRITONEAL    TUBERCULOSIS  265 

take  is  rarely  made  by  I  lie  careful  observer  who  is  familiar  with  this 
class  of  intestinal  tuberculosis,  and  is  on  the  outlook  for  pulmonary 
lesions,  obstruction,  and  other  signs  of  the  disease,  but  where  the 
glands  are  tubercular  and  there  is  a  tumor  formation  a  diagnosis  is 
impossible,  because  the  tuberculin  and  Ehrlich's  diazo-reaction  are 
positive  in  both. 

In  actinomycosis,  which  show^s  a  predilection  for  the  cecum,  the 
neoplasms  resemble  that  of  hyperplastic  tuberculosis,  but  the  former 
induces  greater  pain,  more  frecjuently  breaks  down,  forming  chronic 
sinuses,  the  scrapings  and  discharge  from  which  contain  the  fungus 
(sulphur-like  granules)  of  actinomycosis,  while  in  that  from  tubercular 
fistuke  may  frequently  be  found  tubercle  bacilli. 

The  incidence  of  simple  impaction  in  the  young  and  old  and  fre- 
quency of  neoplastic  tuberculosis  between  twenty  and  forty  is  a  valu- 
able aid  in  the  differentiation  of  the  two  conditions.  Again,  in  cop- 
rostasis  the  tumors  form  more  quickly,  are  apt  to  be  nodulated,  are 
multiple,  indentable,  can  be  manipulated,  and  may  also  be  present  in 
other  segments  of  the  large  bowel.  They  also  excite  a  more  aggravated 
type  of  diarrhea  and  toxemia,  both  of  which,  together  with  the  tumor 
masses,  disappear  when  the  bowel  has  been  cleared  by  massage,  medica- 
tion, or  enemata. 

Right-sided  massi\e  adhesions  from  whatever  cause,  neoplasms  of 
the  ovary,  tube,  and  the  uterus,  osteoma,  nephroptosis  (movable 
kidney),  and  sarcoma  ha\e  probably  been  mistaken  for  tubercular 
neoplasms  in  the  ileocecal  region,  but,  as  a  rule,  they  can  be  easily 
excluded  by  obtaining  a  history  of  the  case,  making  a  thorough  exami- 
nation, and  by  comparing  the  symptoms  and  diagnostic  features  of 
these  diseases  w^ith  those  of  hyperplastic  tuberculosis. 

Giimmata,  as  has  been  pointed  out  in  the  chapter  on  Syphilis,  are 
encountered  very  rarely  in  the  colon,  but  when  found  in  the  cecum 
and  of  fair  size  they  somewhat  resemble  hyperplastic  tubercular 
swellings,  but  can  be  differentiated  from  them  by  the  history  of  a 
previous  chancre,  the  discovery  of  mucocutaneous  syphilids,  spiro- 
chetes, a  positive  Wassermann  and  negative  tuberculin  reeiction,  and 
by  the  administration  of  mercury  and  potassium  iodic!  or  Ehrlich's 
"606,"  which,  if  fcjUowed  by  a  diminution  of  the  size  of  the  growth, 
points  to  a  gumma. 

Psoas  abscesses  may  be  differentiated  by  reflex  pain,  absence  of 
tenderness  on  pressure,  presence  of  fluctuation,  softness  and  changeable- 
ness  in  positi(^n  by  manipulation,  and  its  association  with  sf^inal 
necrosis,  as  indicated  by  the  ensuing  deformity. 

Peritoneal  Tuberculosis. — The  diagnosis  is  at  times  confusing  in 
slow-developing  peritoneal  tuberculosis,  except  when  the  patient  gives 
a  history  of  [)hthisis  and  suffers  from  diarrhea,  and  the  stools  contain 
pus,  blood,  and  mucus.  In  uncomplicated  cases,  where  the  attack 
comes  on  suddenh',  it  is  impcjssible  to  differentiate  tubercular  from 
other  varieties  of  peritonitis  except  by  laparotomy. 


CHAPTER  XXIII 

TUBERCULAR  ENTERITIS,  COLITIS,   AND  ENTEROCOLITIS 
(INTESTINAL  TUBERCULOSIS),  DIARRHEA  IN  {Continued) 

TREATMENT 
PROPHYLACTIC,    DIETARY,    MEDICINAL.    IRRIGATING,    SERUM 

General  Remarks. — The  treatment  of  diarrhea  consequent  upon 
tubercular  lesions  of  the  intestine  (colitis)  can  occasionally  be  carried 
to  a  successful  issue.  In  the  most  favorable  cases  it  requires  a  long 
course  of  treatment  to  arrest  the  process,  and  in  more  aggravated  it  is 
often  impossible  to  effect  a  cure,  and  when  a  good  result  is  obtained, 
annoying  or  dangerous  sequela  often  prevail. 

Routine  treatment  cannot  be  followed  in  this  class  of  cases  because 
of  the  varying  types  and  virulence  of  the  infection,  different  phenomena 
induced  by  them  in  their  constantly  changing  stages,  uncertain  part 
played  by  mixed  infection,  varying  location  and  extent  of  the  disease, 
and  because  in  one  instance  there  is  a  local  condition  to  deal  with,  while 
in  another  foci  are  located,  both  in  the  lung  and  the  bowel;  the  mani- 
festations of  either  may  predominate  or  their  combined  disturbances 
be  of  such  a  nature  as  to  require  special  consideration.  Again,  diar- 
rhea, pain,  hemorrhage,  or  other  symptoms  may  become  suddenly 
so  severe  that  it  is  necessary  to  suspend  other  therapeutic  measures  and 
treat  the  patient  symptomatically  to  relieve  his  suffering  or,  when 
there  is  obstruction,  save  his  life. 

While  it  is  true  that  in  a  few  instances  tubercular  foci  originate  in 
the  bowel  or  perianal  region,  remain  fairly  circumscribed,  induce  but 
moderate  general  manifestations,  and  can  be  cured  by  local  treat- 
ment, it  cannot  be  denied  that  in  most  instances  bowel  tuberculosis 
is  secondary  to  or  complicated  by  lung  involvement,  under  which 
circumstances  serious  general  and  local  manifestations  are  induced 
and  the  patient  requires  both  constitutional  and  local  treatment. 

From  what  has  been  said  it  may  be  inferred  that  the  treatment  is 
variable,  hence  the  author  will  discuss  the  therapeutic  measures  useful 
in  the  treatment  of  intestinal  tuberculosis  under  the  following  head- 
ings: 

(i)  Prophylactic  measures. 

(2)  Measures  for  improving  the  general  health. 

(3)  Medical  treatment. 

(4)  Serum  treatment. 

(5)  Irrigating  treatment. 

(6)  Topical  application  treatment. 

(7)  Surgical  treatment. 
266 


MEASURES  FOR  IMPROVING  THE  GENERAL  HEALTH      267 

Prophylactic  Measures.— The  prophylactic  treatment  of  phthisis 
and  diarrhea  of  intestinal  tuberculosis  in  persons  who  have  inherited 
a  tendency  toward  these  conditions,  have  a  weakened  constitution, 
or  sufTer  from  some  acute  or  chronic  inflammatory  or  ulcerative  dis- 
ease of  the  intestine  consists  in  improving  their  hygienic  surroundings 
by  having  them  sleep  in  well-ventilated  rooms,  exercise  in  the  fresh 
air,  change  a  sedentary  for  a  more  acti\c  occupation,  partake  of  nour- 
ishing food,  avoid  the  dairy  products  of  tuberculous  cows,  exposure, 
rooms  or  sleeping  cars  which  have  been  occupied  by  consumptives, 
irregular  habits,  and  association  with  persons  afflicted  with  tuber- 
culosis. 

It  is  not  known  what  percentage  of  persons  vaccinated  with 
tuberculin  are  prevented  from  contracting  tuberculosis,  nor  has  it  been 
determined  to  what  degree  the  effect  of  the  disease  is  minimized  in 
those  who  become  infected.  However,  since  some  faAorable  results 
have  been  recorded  and  the  inoculation  is  not  dangerous,  it  would 
seem  that  one  is  justified  in  advising  vaccination  for  persons  w'ho  show 
a  weakened  constitution  through  their  inherited  tendency  to  tuber- 
culosis. 

Individuals  already  afflicted  with  phthisis  should  be  compelled  to 
expectorate  into  an  air-tight  receptacle,  and  destroy  the  sputum  to 
prevent  the  drying  and  scattering  of  the  infected  material  which  might 
prove  destructive  to  healthy  individuals.  They  should  be  instructed 
not  to  sw^allow  their  sputum,  to  irrigate  the  cup  and  free  it  of  bacilli, 
and,  finally,  in  country  districts  where  privies  are  used  to  destroy 
the  excrement. 

Measures  for  Improving  the  General  Health. — Some  individuals 
inherit  a  weakened  constitution,  and  persons  afflicted  with  tuberculo- 
sis of  the  bowel,  lungs,  or  both  suffer  from  debility  and  a  lowered  resist- 
ance as  the  result  of  the  tuberculous  process  and  mixed  infection. 

In  proportion  as  we  increase  the  nutrition  and  resistance  of  the 
patient  we  can  prevent  infection,  forestall  auto-inoculation,  and  arrest 
extension  of  existing  foci. 

When  the  patient  is  run  down  and  his  general  condition  needs 
building  up,  this  is  best  accomplished  by  (a)  improving  his  mental 
state;  (b)  requring  him  to  take  tonics  and  tissue  builders;  (c)  rest  dur- 
ing crises;  (d)  live  in  the  open  air  or  w'ith  the  windows  of  his  room 
open;  (e)  indulge  in  moderate  exercise  except  when  weakened  by 
fever  or  diarrhea;  (/)  clothe  himself  coolly  in  summer  and  warmly  in 
winter;  and  (g)  consume  plent\'  of  nourishing  foods  (milk,  cream,  eggs, 
etc.). 

Improving  the  Mental  Conditio?!  of  the  Patient. — Xearl\-  all  tubercu- 
lar subjects  are  in  a  deplorable  state  mentally,  either  because  they 
think  they  have  an  incurable  disease  or  they  worry  over  their  inability 
to  support  their  family.  This  anxiety  is  enough  to  deplete  the  sys- 
tem, for  all  have  observed  strong,  healthy,  phlegmatic  individuals 
lose  in  weight  and  health,  become  extremely  nervous,  and  suffer  from 
digestive  disturbances  through  worrying,  and  if  such  a  condition  ob- 


268     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

tains  in  healthy  indixiduals.  it  emphasizes  the  importance  of  ehminat- 
ing  the  mental  factor  in  tubercular  subjects.  The  condition  of  the 
distorted  mind  can  often  be  quickly  improved  when  the  physician  and 
relatives  of  the  patient  assume  a  spirit  of  cheerfulness,  encourage  him 
by  minimizing  the  seriousness  of  his  condition,  citing  instances  of 
others  similarly  afflicted  who  have  been  cured,  preventing  him  from 
becoming  melancholy  by  means  of  innocent  amusements  or  taking 
him  out  for  a  change  of  surroundings,  and  by  not  constantly  re- 
minding him  of  his  ailment  through  the  frequent  administration  of 
disagreeable  drugs. 

Rest — in  bed  when  the  patient  is  quite  ill,  or  in  a  comfortable  chair 
when  he  feels  better — does  much  toward  relieving  his  mind,  improving 
digestion,  lowering  the  temperature,  preventing  fatigue,  and  over- 
coming insomnia,  conditions  made  worse  by  physical  activity.  Wright 
claims  to  minimize  the  effects  of  the  tubercular  process  by  rest,  and 
has  shown  that  massage  and  mobility  of  tuberculous  foci  induces  the 
formation  of  a  larger  amount  of  tuberculin  than  would  otherwise 
ensue,  which  is  distributed  through  the  body  to  induce  toxic  phenomena. 
Evidence  of  the  injurious  effect  of  active  exercise  in  this  class  of  cases 
may  be  obsen.'ed  in  the  lessening  of  the  opsonic  index. 

The  author  has  frequently  noticed  that  tubercular  subjects  in  a 
sanitarium,  where  rest  constitutes  a  compulsor\-  part  of  the  treatment, 
do  better  than  office  or  dispensan,'  patients  who  receive  ambulatory 
treatment  and  are  not  permitted  sufficient  quiet. 

Exercise. — Both  overactivity  and  inactivity  are  harmful,  and,  be- 
cause of  this,  it  is  necessary  for  these  patients  to  partake  of  a  reason- 
able amount  of  rest  and  of  the  right  kind  of  exercise  to  improve  the 
circulation,  oxygenation,  open  the  skin  pores,  stimulate  the  appetite, 
prevent  muscular  atrophy,  and  cause  the  various  organs  to  function- 
ate properly.  Violent  and  g\'mnastic  or  indoor  exercises  are  contra- 
indicated  because  they  exhaust  him  and  lead  to  his  breathing  dusty 
and  impure  air.  Walking  or  driving  in  the  park  or  woods  constitute 
the  most  suitable  forms  of  exercise,  because  they  afford  entertain- 
ment, fill  the  lungs  with  fresh  air,  stimulate  the  emunctories,  give  the 
patient  a  greater  relish  for  food,  improve  digestion,  lessen  insomnia, 
and  give  him  something  to  do.  It  becomes  necessar^^  to  change  the 
mode  of  exercise,  graduate  or  suspend  it  temporarily  or  altogether 
when  it  tends  to  make  the  patient  restless,  causes  a  rise  in  the  tempera- 
ture, or  fatigue.  In  suitable  cases  shower  or  cool  baths,  followed 
by  friction  with  a  rough  towel  or  massage,  improve  the  condition,  but 
hot  baths,  electricity,  and  vibration  do  little  if  any  good,  because 
they  make  the  patient  nervous  and  increase  the  number  of  the  evacu- 
ations. 

Fresh  Air. — It  has  been  frequently  observed  that  both  men  and 
animals  who  are  cooped  up  in  small,  poorly  ventilated  quarters  develop 
tuberculosis  more  frequently  than  when  they  live  a  free  life  in  the 
open  air  and  are  not  required  to  comply  with  the  exacting  demands  of 
closely  populated  civilized  communities. 


MEASURES    EOR    IMPROVIXC;    THE    GENERAL    HEALTH  269 

Oliver  WcMick'll  Holnu-s  many  years  ago  ex])ressecl  his  view  as  to 
the  \'alue  of  light  and  air  to  man  as  follows: 

"God  lent  his  creatures  li^ht  and  air, 
And  water  open  to  the  skies; 
Man  locks  him  in  a  stilling  lair, 

Anfl  wonders  why  his  brother  dies." 

In  fact,  fresh  air  constilutes  the  essential  feattire  in  the  treatment 
of  tubercular  subjects,  irrespective  of  whether  they  remain  at  home, 
go  to  a  sanitarium,  or  livx'  in  the  wilds  of  a  higher  altitude.  Certainly, 
all  fair-minded  persons  must  admit  that  the  results  obtained  at 
Troudeau's,  the  Loomis,  and  other  sanitaria  elsewhere,  where  the 
fresh-air  treatment  predominates,  are  far  superior  to  the  older  method, 
where  the  patient  was  ctjmpelled  to  remain  at  home  amid  poor 
hygienic  surroundings  and  was  constantly  dosed  with  cod-liver  oil 
and  other  remedies  which  impaired  his  digestion  without  doing  him 
any  good.  Under  the  present  regime  aggravated  cases  with  extensive 
lung  destruction  li\e  much  longer  than  formerly,  and  many  persons 
in  the  incipient  stage  of  the  disease  recover.  The  cure  is  often  per- 
manent, but  reinfection  may  take  place  in  persons  benefited  in  a 
high  altitude  who  suddenly  return  to  a  lower  one  and  live  in  crowded 
districts  amid  their  former  unhealthy  surroundings.  The  fresh-air 
treatment  consists  in  having  the  patient  sleep  in  a  spacious  room 
with  all  the  windows  wide  open,  or  li\'e  and  sleep  in  the  open,  care 
being  taken  to  see  that  he  is  kept  dry,  warm,  and  out  of  drafts. 

The  writer  has  often  observed  marked  improvement  and  a  rapid 
gain  in  weight  in  persons  who  suffered  from  phthisis,  intestinal  or 
anorectal  tuberculosis,  treated  at  home  and  in  sanitaria,  when  they 
obtain  the  necessary  air  in  conjunction  with  the  treatment,  but  it  has 
seemed  to  him  that  the  results  are  more  favorable  when  the  patient 
goes  to  a  higher  altitude  (800  to  1000  feet)  and  spends  most  of  his  time 
resting  or  loitering  about  in  the  fields. 

Clothing  the  patient  properly  is  important,  that  he  may  spend  his 
time  in  tlie  fresh  air  during  the  winter  without  getting  his  feet,  ab- 
domen, or  body  chilled,  which  invariably  aggravates  the  tubercular 
process;  consequently,  it  is  ad\isable  for  him  to  be  clothed  in  woolen 
underwear,  protect  the  chest  and  abdomen  from  cold  by  a  pad  or 
binder,  and  the  feet  and  otiter  clothing  from  getting  wet  by  means  of 
rubber  shoes  and  a  raincoat.  In  summer  the  clothing  should  be  of  a 
lighter  material  so  he  will  not  perspire  freely,  which  would  tend  to 
exhaust  and  cause  him  to  take  cold. 

Change  of  Occupation. — Frequently  the  infection  is  attributable 
to,  or  the  condition  of  individuals  already  afflicted  with  tuberculosis 
is  greatly  aggravated  by,  the  patient's  occupation,  which  requires  him 
to  live  a  sedentary  life,  or  a  more  active  one  in  the  midst  of  small, 
poorly  ventilated  rooms,  in  factories,  mines,  etc.,  where  the  lungs 
are  frequently  irritated  by  the  inhalation  of  vitiated  gases  and  dust, 
and  which  necessitates  his  suddenly  changing  froin  one  temperature 


270     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

to  another  (as  is  the  case  in  iron  foundries  and  cold-storage  plants), 
or  keeps  him  exposed  to  all  kinds  of  weather.  If  this  is  the  case,  it  is 
the  duty  of  the  physician  to  advise  tubercular  subjects  to  change  their 
abode,  and,  when  necessary,  the  occupation,  if  it  is  responsible  for  the 
condition,  because  improvement  will  not  take  place  under  the  pre- 
vailing conditions,  and  when  a  cure  has  been  accomplished  through  a 
change  of  location,  fresh  air,  and  good  food  they  should  be  prevented 
from  returning  to  the  surroundings  which  brought  on  their  illness. 

Dieting. — Proper  control  of  the  diet  constitutes  a  valuable  feature 
in  all  inflammatory  ulcerative  and  stenotic  lesions  of  the  intestine 
which  induce  diarrhea,  particularly  of  tubercular  origin.  Dieting 
is  rarely  curative  in  itself,  but  is  an  aid  in  the  symptomatic  treatment 
of  intestinal  tuberculosis,  a  fact  easily  demonstrable  by  having  the 
patient  change  from  suitable  to  foods  which  disagree  with  him  and 
vice  versa.  It  plays  a  much  more  important  part  in  the  treatment  of 
tuberculosis  located  in  the  small  than  in  the  large  bowel  and  rectum, 
which  are  not  so  sensitive  to  a  change  in  the  secretions  or  irritation 
from  food  remnants.  The  patient  should  have  two  diet  lists — one 
containing  food  he  can  eat  and  the  other  that  which  he  cannot.  This 
practice  works  well  in  some  instances,  but  in  other  cases  the  results  are 
not  good,  because  the  edibles  suitable  to  one  individual  frequently 
aggravate  the  condition  of  another,  and  the  amount  of  food  that  can 
be  digested  varies  with  different  persons. 

When  outlining  a  diet  it  is  well  to  take  into  consideration  the  type 
of  infection  and  its  progress,  because  some  forms  and  stages  of  a 
tubercular  process  appear  to  be  more  sensitive  to  the  action  of  food 
than  others — viz.,  cramps,  gas  distention,  and  diarrhea  are  less  pro- 
nounced in  enteric  than  in  enteroperitoneal  tuberculosis  where  the 
lesions  are  extensive  and  involve  the  entire  gut  wall. 

While  the  author  acknowledges  the  value  of  controlling  the  diet, 
he  believes  dieting  is  often  overdone  to  the  patient's  detriment,  be- 
cause a  sufficient  amount  of  suitable  nourishing  food  is  not  prescribed 
to  sustain  metabolism. 

The  author  will  now  list  the  foods  which  should,  and  those  which 
should  not,  be  permitted  in  the  average  case  of  tubercular  diarrhea, 
viz. : 

Foods  Permitted. — When  the  evacuations  are  frequent,  solid  foods 
which  leave  a  coarse,  bulky,  irritating  residue  should  be  prohibited  and 
the  patient  placed  upon  a  liquid  or  semisolid  diet,  consisting  of  milk, 
koumiss,  zoolak,  or  buttermilk  (when  well  borne),  strained  gruels, 
milk-toast,  cocoa,  ordinary  and  beef- tea,  nourishing  soups;  and  later, 
cereals,  raw  or  soft-boiled  eggs,  rennet  and  custard,  until  the  attack 
has  subsided,  when  he  may  be  permitted  to  eat  butter,  cream,  vegetable 
purees,  sparingly  of  squab,  chicken  or  quail,  certain  well-cooked  vari- 
eties of  fish,  scraped  beef,  and  other  foods  which  experience  has  shown 
he  can  digest.  When  the  lesions  are  confined  exclusively  to  the 
lower  bowel,  a  chop  or  small  piece  of  steak  may  be  allowed  once  daily 
during  the  intervals  of  attacks. 


MEDICAL    TREATMENT  2~l 

Foods  Prohibited. — As  a  rule  the  following  articles  of  diet  should  be 
excluded  in  acute  and  chronic  tubercular  diarrhea:  raw  fruits,  cold 
drinks,  ice-cream,  cold  carbonated  beverages,  cider,  honey,  berries, 
fruit  juices,  dates,  cabbage,  beets,  roots,  or  vegetables  rich  in  cellulose, 
coffee,  cheese,  fresh  or  hot  bread,  potatoes,  meat  in  large  quantities, 
shell-fish  or  other  edibles  which  resist  the  digestive  juices,  chill  the 
intestine,  or  irritate  the  inflamed  and  ulcerated  mucosa. 

From  what  has  been  said  it  will  be  seen  that  a  routine  diet  in  this 
afifection  is  impossible,  and  that  it  is  necessary  to  change  the  food  from 
time  to  time. 

Medical  Treatment. — Usually  at  one  time  or  another  drugs  are 
necessary  in  the  treatment  of  the  various  forms  of  intestinal  tuber- 
culosis, and  particularK-  when  diarrhea  is  the  dominant  symptom. 
The  author  knows  of  no  drug  which  is  a  specific  in  bowel  tuberculosis. 
In  fact,  he  believes  that  more  good  comes  from  medicine  symptomat- 
ically  prescribed  than  when  it  is  administered  with  the  object  of 
curing  the  patient.  He  does  not  question  but  that,  with  the  aid  of 
the  remedies  hereafter  described,  the  degree  of  pain,  amount  of  gas 
distention,  and  frequency  of  the  stools  and  other  manifestations  con- 
sequent upon  the  diseased  bowel  can  be  diminished  or  temporarily 
alleviated,  but  does  doubt  whether  they  do  any  permanent  good 
through  actual  healing  of  the  inflamed  or  ulcerated  mucosa  responsible 
for  the  diarrhea.  Many  times  he  has  seen  diarrhea  partially  or  com- 
pletely checked  for  days,  weeks,  and  even  months  with  drugs,  only  to 
start  up  again  as  soon  as  they  had  been  stopped.  If  medicines  ad- 
ministered by  mouth  cannot  be  relied  upon  in  this  class  of  cases,  they 
should  be  discarded  or  seldom  prescribed,  because  drugs  disturb 
digestion,  impair  the  appetite,  diminish  the  secretions  and  upset  the 
ner\-ous  apparatus,  and  cause  the  subject  to  become  habituated  to 
them,  and  when  insoluble  often  collect  and  form  enteroliths  which 
constantly  irritate  the  intestine  or  obstruct  the  bowel.  Therefore, 
more  reliance  should  be  placed  on  the  therapeutic  measures  elsewhere 
recommended  in  the  treatment. 

On  several  occasions  the  writer  has  removed  black,  putty-like, 
bismuth  accumulations  which  varied  in  amount  from  a  few  ounces  to 
as  much  as  3  pounds  in  one  instance,  and  others  have  removed  similar 
accumulations  of  bismuth  and  salol.  Bismuth  impactions,  because 
of  their  insolubility-,  cannot  be  dissolved  or  dislodged  by  catharsis  or 
enemata,  and  must  be  evacuated  with  a  spoon  or  the  fingers  when  near 
the  anus,  and  through  the  sigmoidoscope,  with  a  narrow,  long-handled 
scoop,  when  higher  up.  Such  accumulations  are  black,  putty-like,  and 
result  from  the  continued  daily  administration  of  large  amounts  of 
bismuth  to  control  chronic  diarrhea. 

In  one  case  the  author  removed  altogether  four  bismuth  tumors 
(orange  size)  from  a  patient  who  had  taken  the  drug  for  three  years, 
the  first  of  which  was  delivered  six  months,  the  second  nine  months, 
and  the  third  a  year  and  a  half  after  she  had  stopped  taking  the  drug, 
and  the  fourth  four  years  following  the  last.     At  the  time  the  first  mass 


272      TUBERCULAR    ENTERITIS.    COLITIS,    ENTEROCOLITIS.    DIARRHEA    IN 

was  evacuated  others  could  be  felt  in  the  cecum  and  transverse  colon, 
but  evidently  the  bowel  had  become  tolerant  to  the  chemical,  since 
it  caused  no  further  discomfort  than  sensations  of  fulness  and  weight 
in  the  bowel. 

In  another  patient  (a  young  man  of  twenty)  who  suffered  from 
rectal  carcinoma  and  frequent  movements  incident  to  the  obstruction, 
an  enormous  tumor  was  located  by  digital  examination  and  abdomi- 
nal palpation,  the  lower  extremity  of  which  was  hard,  the  middle  soft, 
and  the  upper  part  fairly  firm  and  nodulated,  and  a  later  examination 
and  exploratory  incision  proved  the  lower  rectal  portion  to  be  carcino- 
matous, the  middle  bismuth  putty,  and  the  upper  a  fecal  impaction. 
The  growth,  which  at  first  appeared  inoperable,  was  easily  removed 
by  perianal  excision  following  dislodgment  of  the  feces  and  bismuth 
with  a  gouge,  and  enemata  introduced  through  a  proctoscope  inserted 
beyond  the  cancerous  obstruction. 

For  purposes  of  convenience  the  author  will  now  discuss  the 
medicines  and  sera  which  have  been  most  successfully  employed  in 
the  treatment  of  tubercular  diarrhea  under  the  following  headings: 

(i)  Tonics. 

(2)  Antiseptic  and  soothing  agents. 

(3)  Symptomatic  remedies. 

(4)  Irrigating  solutions. 

(5)  Topical  remedies, 
(6>  Serum  treatment. 

Tonic  Remedies. — Tonics  are  prescribed  with  the  object  of  improv- 
ing the  digestive  apparatus,  increasing  metabolism  and  building  up 
the  general  condition  of  the  patient,  but  they  are  unreliable  except 
when  employed  in  combination  with  the  other  and  better  therapeutic 
measures  elsewhere  recommended  in  the  treatment  of  persons  afflicted 
with  phthisis,  intestinal  tuberculosis,  or  both. 

There  can  be  no  question  that  this  class  of  patients  need  fats, 
and  that  they  should  be  prescribed  liberally  in  the  form  of  milk, 
cream,  butter,  cream  cheese,  thinly  sliced  and  properly  cooked  bacon, 
and  in  the  incipient  stages  non-irritating  oils  (olive  and  almond)  may 
be  given  when  tolerated,  because  they  soothe  the  inflamed  bowel  and 
supply  a  much-needed  food.  The  author  has  often  obser\'ed  marked 
improvement  follow  the  administration  of  Russell's  emulsion  of  mixed 
fats  and  vegetable  products  (  5ss — 15)  three  times,  daily,  in  connection 
with  the  open-air  treatment.  His  patients  have  not  been  improved 
through  giving  them  an  emulsion  or  other  cod-liver  oil  preparation,  but 
he  has  known  these  remedies  to  make  them  worse  by  destroying  the 
appetite  and  interfering  with  digestion.  Better  results  are  usually 
obtained  from  forced  feeding  and  keeping  the  patients'  bowels  open 
by  laxatives  than  from  the  medicinal  tonic  treatment. 

In  suitable  cases,  where  the  patient  is  anemic,  run  down,  nervous, 
and  has  an  irritable  cough,  considerable  relief  is  to  be  had  from  the 
administration  of  iron  (reduced  iron),  gr.  i  to  2  (0.06-0.12);  the  sul- 
phate, gr.  h  to  I   (0.03-0.06);  Blaud's  pills,  i  to  2;  arsenic  (Fowler's 


ANTISEPTIC    AXD    SOOTIIIXG    REMEDIES  273 

solution),  np  2  to  10  (0.12-0.60);  creosote,  nj  i  to  3  f 0.06-0.1 8);  guaia- 
col,  TTj  8  (0.50);  guaiacol  carbonate,  gr.  10  to  15  (0.60-1.0),  individually 
or  simultaneously. 

Sergent  has  been  treating  pulmonan.-  tuberculosis  according  to 
Ferrier's  recalcification  lime  treatment  to  resupph-  lime,  the  loss  of 
which,  he  believes,  prepares  the  soil  for  tuberculosis  and  promotes  its 
de\elopment,  and  considers  it  the  best  method  of  treating  tuberculosis 
because  it  prevents  the  undue  loss  of  lime  and  favors  recalcification. 
He  has  employed  the  method  in  1574  cases,  and  states  that  306  patients 
have  been  under  observation  for  from  six  months  to  five  years,  and 
general  improvement  was  marked  in  96  per  cent. ;  general  and  local, 
in  40  per  cent. ;  14  per  cent,  were  apparently  cured,  while  in  14  per  cent, 
the  disease  was  unmodified.  Ferrier  assumes  that  the  principal  cause 
of  the  loss  of  lime  is  acid  fermentation  in  the  digestive  tract,  which 
must  be  prevented  and  combated  b>'  lime  salts  given  in  substance  and 
in  mineral  waters. 

The  treatment  of  pulmonary  tuberculosis  by  the  hypodermic 
injections  of  succinimid  of  mercury  (gr.  \,  [0.013]  in  ttp  10  [0.60]  of 
water)  into  the  deep  muscles  of  the  buttock  has  proved  beneficial  in 
several  cases  treated  by  Dr.  Barton  L.  Wright  (V.  S.  Army),  who 
originated  the  method,  and  others.  He  made  thirt\'  injections  on 
alternate  days,  and  then  substituted  potassium  iodid  tablets,  10  gr. 
(0.60),  in  a  wineglass  of  water  three  times  daily  during  the  following 
two  weeks,  after  which  medication  was  stopped  for  a  week,  and  then 
the  mercurial  injections  were  again  started  and  the  method  continued 
as  long  as  necessary-.  In  most  cases  the  physical  signs  and  number  of 
bacilli  rapidly  decreased  following  the  injections,  and  in  some  instances 
the  improvement  was  permanent,  but  in  others  relapses  occurred. 

Brown  recommends  iodin  injections  in  phthisis  and  tuberculosis  of 
the  bmvel — viz. : 

I^.     Iodoform gr.  c  (6.70); 

Acacia  powder gr.  xx\'  (1.70); 

Glycerin njcc  (13.3) ; 

Carbolic  acid iigv  (0.30) ; 

Boiled  distilled  water tijccc  (20.0). — ^I. 

Dose. — 12  to  14  gr.  (0.70-0.85)  for  non-pulmonarj-  cases;  8  to  12  gr.  (0.50-0.70)  for 
pulmonary  cases. 

The  injection  is  followed  by  a  rise  of  temperature  for  a  day  or  two, 
and  is  repeated  ever\'  two  or  three  weeks.  Several  cases  are  reported 
in  which  marked  improvement  or  a  cure  resulted. 

Antiseptic  and  Soothing  Remedies. — The  internal  administration 
of  so-called  gastro-intestinal  antiseptics  has  been  extensively  practised 
by  the  author  among  his  private  and  dispensary-  patients  for  a  number 
of  years,  and  the  different  remedies  recommended  for  the  purpose  have 
l)een  prescribed  in  small  and  large  doses  in  the  various  types  of  in- 
flammatory and  ulcerative  lesions  of  the  intestine,  including  tuber- 
culosis, with  the  result  that  he  has  found  antiseptics  unreliable  in  so  far 
as  their  germicidal  powers  are  concerned. 
18 


274     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS.    DIARRHEA    IN 

In  some  cases  microbic  activity  seemetl  to  be  temporarily  counter- 
acted by  antiseptic  drugs  taken  by  the  mouth,  but  no  permanent  benefit 
followed  their  administration,  probably  because  if  the  dosage  had 
been  sufficient  to  accomplish  the  purpose  the  patient  would  have  died 
from  the  effects  of  the  medicine. 

Recent  authorities  on  gastro-enterology  have  but  little  to  say  in 
favor  of  the  antiseptic  treatment  of  bowel  diseases  in  comparison  to 
what  was  said  in  their  favor  a  few  years  ago,  shortly  following  the 
publication  of  Bouchard's  work  on  "Auto-intoxication  in  Disease." 

Antiseptics  are  frequently  prescribed  with  the  idea  of  lessening 
intestinal  fermentation  and  putrefaction,  neutralizing  toxins  of 
retained  discharges  and  feces,  and  preventing  the  multiplication  of 
pathogenic  bacteria,  but,  in  so  far  as  the  author's  experience  is  con- 
cerned, the  administration  of  these  drugs  with  the  object  of  arresting 
diarrhea  incited  by  tubercular  foci  through  destruction  of  the  bacilli 
is  utterly  useless,  because,  in  his  opinion,  they  are  not  destroyed,  and 
it  is  doubtful  if  they  are  even  attenuated. 

It  is  evident  that  tubercle  bacilli  have  considerable  resistance 
against  these  remedies  and  acid  media  because  they  successfully  pass 
through  antiseptic  juices  (acid)  of  the  stomach  and  the  digestive 
secretions  of  the  small  intestine,  which  are  supposed  to  have  certain 
bactericidal  powers.  The  chances  are,  that  if  a  drug  were  discovered 
which  would  successfully  destroy  these  and  other  pathogenic  bacteria 
it  would  interfere  with  the  digestive  process,  poison  the  patient,  or 
destroy  the  mucosa.  A  serum  is  more  likely  to  be  discovered  which, 
acting  through  the  blood,  would  prevent  and  cure  tubercular  lesions 
than  a  chemical  which  would  produce  a  cure  through  its  local  effect 
upon  bacteria. 

The  following  are  the  medicines  which  have  accomplished  the 
best  results  in  the  antiseptic  treatment  of  tubercular  and  other  spe- 
cific lesions  in  the  small  intestine  and  colon,  used  alone  or  in  com- 
bination with  other  drugs — viz.,  calomel,  gr.  |  to  2  (0.03-0.12); 
bismuth  subnitrate,  gr.  10  to  30  (0.60-2.0);  carbonate,  gr.  10  to  20 
(0.60-1.30);  subsalicylate,  gr.  i  to  3  (0.06-0.18);  beta-naphthol,  gr. 
I  to  3  (0.06-0.18);  creosote,  nj  i  to  2  (0.06-0.12);  formol,  salol,  gr. 
3  to  10  (0.18-0.60);  tannoform,  gr.  4  to  8  (0.24-0.50);  dilute  solutions 
of  hydrochloric  (ttp  10  to  15  [0.60-1.0])  and  sulphuric  acid  (tnj  10  to  20 
[0.60-1.30]);  boric  acid,  gr.  5  to  10  (0.30-0.60);  benzoate  of  soda, 
gr.  10  to  15  (0.60-1.0);  fortoin  (cotoin-formaldehyd,  recommended 
by  Rotschild  in  treatment  of  tubercular  diarrhea  because  of  its  favor- 
able influence  upon  the  circulation),  gr.  4  to  8  (0.24-0.50),  three  times 
daily;  catechu,  gr.  8  (0.50);  and  fortoin,  gr.  4  (0.24),  one  powder  three 
times  daily. 

Renon  and  Grundel  have  employed  methylene-blue  in  54  cases 
wherein  the  stools  rapidly  diminished  from  fifteen  to  twenty  to  nor- 
mal within  three  days.  The  methylene-blue  was  administered  in 
i|-gr.  (0.09)  doses  combined  with  lactose  to  make  it  more  tolerant. 
The  improvement  noted  outweighs  the  disadvantages  of  the  drug, 


ANTISEPTIC    AND    SOOTHING    REMEDIES  275 

which  discolors  the  urine  and  produces  an  unpleasant  taste.  The 
writer  has  for  years  employed  this  remedy  in  the  local  treatment  of 
tubercular  and  other  intestinal  lesions,  and  the  remarkably  good  re- 
sults following  its  empUnnient  ha\-e  been  attributed  to  its  antiseptic, 
soothing,  and  healing  (|ualities. 

Calomel  in  divided  doses  (gr.  \  [0.015]  repeated),  where  the  patient 
has  bilious  attacks,  helps  in  getting  rid  of  surplus  bile  and  diminishing 
fermentation  and  putrefaction,  particularly  when  followed  next  morn- 
ing by  a  moderate  dose  of  citrate  or  sulphate  of  magnesia,  mineral 
draft,  or  Seidlitz  powder. 

Of  the  antiseptics  named,  beta-naphthol,  subnitrate  of  bismuth, 
and  salol  alone  or  in  combination  have  given  the  best  results  in  the 
author's  practice,  but  more  through  their  soothing  and  protective 
action  upon  the  inflamed  and  ulcerated  mucosa  than  by  their  anti- 
septic action  upon  the  intestinal  contents. 

Others  of  the  more  reliable  soothing  and  protective  remedies  are 
the  carbonate  and  phosphate  of  calcium,  gr.  10  to  30  (0.60-1.30); 
pulverized  chalk,  gr.  15  to  60  (1.0-4.0);  charcoal,  gr.  15  to  30  (1.0-2.0), 
alone  or  in  combination  with  olive  oil,  neutratol,  etc.,  in  tablespoonful 
or  larger  doses  twice  daily,  when  the  oil  does  not  upset  the  stomach. 

Bismuth  subnitrate  and  salicylate  are  useful  because  they  are 
constipating,  have  a  sedative  and  styptic  action  upon  the  inflamed 
mucosa,  stimulate  the  healing  of  lesions,  have  a  decomposing  eff"ect 
upon  sulphuretted  hydrogen,  and  can  be  administered  for  days,  months, 
or  years  in  lo-gr.  (0.60)  or  larger  doses  from  three  to  five  times  daily 
without  disturbing  digestion.  The  principal  objection  to  their  con- 
tinued administration  is  that  they  ma>'  accumulate  and  form  entero- 
liths that  cause  partial  or  complete  obstruction. 

Routine  dosage  is  impossible  with  these  remedies  in  the  treatment 
of  diarrhea  of  tubercular  origin,  because  a  much  greater  amount  is 
required  in  one  case  than  another  on  account  of  tolerance  on  the  part 
of  the  patient  or  virulence  of  the  infection.  The  accompanying  for- 
mulae can  be  relied  upon  to  relieve  pain  and  limit  the  stools  in  emer- 
gency cases: 

I^.     Ext.  opii gr.  g  (o.oi); 

Bismuth  salicylatis gr-  iij  (0.18). — M. 

Ft.  pilulas  No.  i. 
Sig. — One  three  times  daily. 

I^.     Syr.  zingib ttijxI  (2.60) ; 

Tr.  opii iTjjiv  (0.24); 

Mist,  creta? q.  s.  ad  5ss  (15.0). — M. 

Sig. — Tablespoonful  ever>-  four  hours. 

rj.     Pulv.  cretae  compos gr.  xv  (i.o); 

Bismuth  subgallate gr.  v  (0.30); 

Aq.  menthae  piperitse q.  s.  ad  5ss  (15.0). — M. 

Sig. — Tablespoonful  every  four  hours. 

I^.     Tr.  krameria ir^xxx  (2.0) ; 

Tr.  opii npv  (0.30) ; 

Mist,  cretas q.  s.  ad  3ss  (15.0). — M. 

Sig. — Tablespoonful  every  four  hours. 


276     TUBERCULAR    ENTERITIS,    COLITIS.    ENTEROCOLITIS,    DIARRHEA    IN 

Antiseptics  administered  by  mouth  often  accomplish  ver>-  little 
in  the  treatment  of  intestinal  tuberculosis,  but  when  these  same 
remedies  are  applied  directly  to  the  diseased  mucosa  in  the  form  of 
a  powder  (by  inflation)  or  irrigating  solutions  improvement  in  the 
patient's  condition  rapidly  follows. 

Symptomatic  Remedies. — It  frequently  becomes  necessan,-  to 
temporariK-  suspend  the  curative  treatment  of  intestinal  tuberculosis 
and  direct  our  efforts  against  a  particular  symptom  which  distresses 
the  patient  greatly. 

The  most  frequent  and  pronounced  s\mptom  of  tubercular  lesions 
of  the  bowel  is  intermittent  or  continuous  diarrhea.  In  mild  cases 
the  movement  can  be  controlled  fairly  well  with  antiseptics  and 
astringents,  but  where  the  lesions  are  extensive  and  there  is  marked 
infection,  the  number  of  stools  can  be  diminished  but  not  arrested. 
When  disease  of  the  stomach  or  small  intestine  complicates  tubercular 
foci  in  the  colon,  it  must  be  treated  also;  otherwise  the  diarrhea  will 
not  be  entirely  relieved. 

Of  the  antidiarrheal  medicines,  opium  constitutes  the  remedy  par 
excellence,  and  invariabh'  partially  or  completely  controls  the  evacua- 
tions. This  useful  adju\ant  in  the  treatment  of  tubercular  diarrhea 
and  accompanying  cramps  and  pain  may  be  used  alone  or  in  combina- 
tion in  the  following  forms  and  dosage — viz.,  pulveris,  gr.  i  to  if 
(0.06-0.09);  extract,  gr.  \  (0.03);  tincture,  n^  5  to  10  (0.30-0.60); 
camphorated  tincture  of  opium.  3  j  to  ij  (4.0-8.0);  Dover's  powder, 
gr.  5  to  10  (0.30-0.60);  morphin  sulphate,  gr.  |  to  J  (0.008-0.015); 
codein  sulphate,  gr.  J  to  i  (0.015-0.06);  heroin,  gr.  tV  to  oir  (0.006- 
0.003). 

The  drug  may  be  administered  by  mouth,  hypodermically,  or 
in  the  form  of  suppositories,  according  to  the  urgency  of  the  case 
or  inclination  of  the  patient.  A  few  decades  ago  opium  was  almost 
universally  prescribed  in  the  form  of  a  powder  or  pill,  but  many  phys- 
icians today  prefer  morphin,  heroin,  or  codein.  The  latter  are  more 
convenient  and  are  taken  with  better  grace,  but  powdered  or  gum 
opium  controls  the  movements  and  accompanying  discomforts  better 
because  its  action  is  due  to  the  contained  resin.  The  beneficient  effect 
of  opium  in  tubercular  diarrhea  is  due  to  its  power  of  inhibiting  peris- 
talsis, favoring  absorption  and  nutrition  (by  quieting  the  bowel), 
relieving  muscular  spasm,  quieting  the  pain  from  gas  accumulations, 
and  checking  the  secretions. 

From  a  curative  standpoint  opium  serves  to  tie  up  the  bowel,  so  that 
it  acts  as  a  splint  and  keeps  the  intestinal  lesions  within  it  quiet  and 
gives  them  an  opportunity  to  heal.  When  enterospasm  is  frequent  or 
severe,  good  results  are  obtainable  by  combining  gr.  i  to  j  (0.008- 
0.015)  of  the  extract  or  tluidextract  of  belladonna  with  it. 

When  there  is  hyperfermentation  or  putrefaction,  or  the  bowel  is 
irritable,  an  antiseptic,  astringent,  or  sedative  remedy  may  be  com- 
bined with  opium  to  advantage.  The  frequent  stools  of  tubercular 
diarrhea  can  generally  be  controlled  by  the  administration  of  Dover's 


SYMPTOMATIC    REMEDIES  277 

powder,  gr.  lo  (0.60),  and  bismutli  sul)nitrate  or  carbonate,  gr.  30 
(2.0),  three  or  more  times  daily. 

Where  the  stomach  is  easily  upset  or  the  patient  suffers  from  rectal 
tenesmus  and  pain,  suppositories  containing  cocain  or  morphin, 
gr.  I  (0.015),  in  combination  with  belladonna,  gr.  ^  (0.008),  inserted 
two  or  three  times  daily,  do  much  tcnvard  relieving  the  patient's  suffer- 
ing and  reducing  diarrhea. 

Styptic  remedies  alone,  or  in  combination  with  opium  or  bismuth, 
are  largely  relied  upon  by  some  physicians  to  control  diarrhea  and 
encourage  intestinal  ulcers  to  heal.  Of  the  astringents,  lead  acetate, 
gr.  I  (0.06) ;  alum,  gr.  5  (0.30) ;  tannic  acid,  gr.  5  to  8  (0.30-0.50) ; 
tincture  of  cocoa,  gtt.  5  to  10  (0.30-0.60) ;  gallic  acid,  gr.  10  to  15  (0.60- 
i.o);  tannalbin,  gr.  15  to  60  (1.0-4.0);  tannigen,  gr.  4  to  8  (0.24-0.50); 
tannocol,  gr.  10  to  15  (0.60-1.0);  ichthoform,  gr.  15  to  30  f  1.0-2.0); 
ichthalbin,  gr.  15  to  30  (1.0-2.0);  subgallate  of  bismuth,  gr.  5  to  20 
(0.30-1.30);  and  silver  nitrate,  gr.  lyV  to  ^V  (0.001-0.002),  in  oij  (8.0) 
of  water  every  two  hours  (Jacoby),  have  been  most  frequently  em- 
ployed. 

Silver  nitrate  is  very  effective,  but  sometimes  when  long  continued 
gives  to  the  skin  a  darkened  and  phosphorescent  hue  (argyria). 

Acetate  of  lead,  in  combination  with  opium,  is  serviceable  for  check- 
ing diarrhea  and  in  alleviating  cramps  and  abdominal  soreness,  and, 
when  used  in  connection  with  hot  moist  applications  to  the  abdominal 
wall,  reduces  muscular  rigidity. 

Counter  indications  to  antidiarrheal  remedies  in  the  treatment  of 
intestinal  tuberculosis  are  stricture,  fecal  impaction,  enteroliths,  re- 
tained discharges,  and  putrefying  foods. 

It  is  advisable  to  prescribe  appetizers,  tonics,  and  other  remedies 
which  will  aid  digestion,  so  that  the  patient  can  digest  a  reasonable 
amount  of  food  and  keep  up  metabolism.  The  gastric  and  intestinal 
contents  should  be  examined  as  to  their  alkalinity  or  acidity,  so  that  in 
case  either  is  deficient  the  trouble  can  be  corrected  by  having  the 
patient  take  dilute  hydrochloric  or  sulphuric  acid  in  small  doses  where 
there  is  hypo-acidity;  or  magnesia,  bicarbonate  of  soda,  or  lime-water 
when  there  is  hyperacidity. 

Pepsin  may  be  combined  with  h>'drochloric  acid  to  advantage  in 
gastric  atonic  dyspepsia,  but  when  the  dyspepsia  is  of  intestinal  origin 
pancreatin  is  useful,  and  nux  vomica  and  gentian  can  be  relied  upon  to 
tone  up  the  gastric  glands  and  clear  up  bilious  attacks. 

Cohnheim  recommends  the  tincture  of  creosote,  gtt.  8  (0.50)  in 
a  spoonful  of  red  wine  three  times  daily,  in  the  treatment  of  tuber- 
cular dyspepsia,  the  amount  being  gradualK*  raised  to  gtt.  30  (1.3), 
which  is  continued  for  three  months. 

Fever  which  cannot  be  controlled  by  rest,  fresh  air,  tei:)id  water,  or 
alcohol  sponge  baths  should  be  kept  within  bounds  by  antipyretic 
agents — aspirin,  antipyrin,  etc.,  gr.  5  to  10  (0.30-0.60),  three  times 
daily — remedies  to  be  avoided  if  j^ossible,  because  of  their  usualh'  harm- 
ful effects  upon  the  heart. 


278     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IX 

Night-sii'eats  can  be  speedily  overcome  by  forced  feeding  and  the 
fresh-air  treatment,  but  when  they  cannot  a  few  drops  of  the  tincture 
of  belladonna  or  the  injection  of  atropin,  gr.  too  (0.0006),  usually 
accomplish  the  desired  results. 

In  this  connection  it  might  be  of  interest  to  note  that  Flemer  has 
obtained  some  very  good  results  with  gelatin  in  the  treatment  of 
intestinal  tuberculosis,  and  that  Heiser  has  found  that  where  tuber- 
culosis and  hookworm  coexist  the  former  is  much  easier  placed  under 
control  when  the  latter  has  been  eliminated. 

Irrigating  Treatment. — The  irrigating  treatment  of  intestinal  tu- 
berculosis is  always  beneficial,  but  the  results  from  it  are  much  better 
in  some  than  other  forms. 

It  is  more  effective  in  the  enteric  or  superficial  ulcerative  than 
in   either    the  enteroperitoneal  (Fig.  39),   hyperplastic,  fibrosclerotic, 


Fig.  39. — Tubercular  ulcers  of  the  colon.  Note  their  number,  large  size,  and  lack  of 
tendency  toward  girdle  formation.  The  rounded  edges  of  the  lesions,  the  scar  tissue,  and 
puckered  condition  of  the  mucosa  indicate  that  the  tubercular  process  has  been  arrested.^ 

glandular,  or  peritoneal  varieties,  because  the  lesions  here  are  limited 
to  the  superficial  layers  of  the  mucosa,  which  are  easily  reached, 
cleansed,  and  stimulated  by  the  medicated  fluid. 

In  the  enteroperitoneal  or  deep  ulcerative  type,  where  the  mucosa, 
serosa,  or  entire  bowel  wall  are  involved,  enteroclysis  helps  directly 
and  indirectly  to  improve  the  patient's  condition  by  dislodging  irritating 
feces,  debris,  and  discharges,  neutralizing,  destroying,  or  evacuating 
toxins,  attenuating,  killing,  or  flushing  out  tubercle  bacilli  and  other 
pathogenic  organisms,  healing  ulcers  and  limiting  extension  of  the  dis- 
ease by  improving  the  bowel  resistance,  purifying  the  circulating  fluids, 
and  minimizing  the  danger  from  specific  and  mixed  infection. 

Except  in  the  above-mentioned  ways  these  measures  are  of  little 
'  .\rmy  Med.  Museum. 


IKRIGATINCi    TRKATMENT  279 

consequence  in  the  treatment  of  this  type  of  tuberculosis  once  the  foci 
have  become  estabhshed  in  the  serosa,  muscularis,  and  mesenteric  or 
retroperitoneal  glands. 

In  hyperplastic  {tumor-forming)  tuberculosis  the  neoplasm  is  fre- 
quently located  in  the  cecal  region  or  rectum,  induces  a  marked  inflam- 
matory reaction  in  the  intestines,  but  does  not  ulcerate  until  late  when 
it  has  assumed  considerable  size.  Consequently,  enteroclysis  ac- 
complishes very  little  in  the  earlier  stages  of  neoplastic  tuberculosis, 
but  later,  when  tubercular  mixed  infection  and  stercoral  ulcers  are 
present,  it  does  considerable  toward  preventing  extension  of  the  ul- 
cerated areas,  formation  of  abscesses,  and  auto-intoxication,  arresting 
hemorrhage,  neutralizing  poisons,  ridding  the  bowel  of  irritating  dis- 
charges, toxins,  and  bacteria,  evacuating  gas  accumulations,  and  re- 
lieving soreness,  cramps,  muscular  rigidit\",  and  pain  wlien  employed 
hot  (100°  to  110°  F.). 

This  type  of  tuberculosis  is  not  curable  by  enterochsis  or  medi- 
cated irrigations  because  the  disease  extends  intrinsically  and  ex- 
trinsically  by  cell  proliferation,  forming  tubercular  masses  of  such 
size  that  the  solution  could  not  be  expected  to  cause  its  obliteration 
since  it  does  not  reach  all  parts  of  the  growth.  The  statistics  given  in 
the  surgical  treatment  show  that  numerous  cases  have  been  reported 
where  tubercular  neoplasms  have  been  diminished  or  made  to  disap- 
pear by  short-circuiting  the  involved  gut,  probably  through  affording 
rest  to  the  affected  part.  If  hyperplastic  tuberculosis  is  amenable  to 
this  procedure,  it  should  be  still  more  so  to  proper  intestinal  irrigations 
which  diminish  peristalsis,  soothe  the  inflamed  bowel,  heal  ulcers, 
and  cleanse  the  infected  area  of  bacteria,  toxins,  discharges,  and  other 
irritants.  Quicker  and  better  results  are  obtained  when  through-and- 
through  irrigation,  described  elsewhere.'  is  pro\ided  for  at  the  time  of 
short-circuiting,  to  prevent  backing  up  of  the  feces  and  permit  bowel 
flushing.  This  combined  procedure  is  devoid  of  the  dangers  of  re- 
section, and  is  indicated  in  all  cases  where  the  patient  declines  extir- 
pation of  the  neoplasm  or  its  removal  is  impracticable  and  as  a  tr}--out 
with  a  view  to  resection  in  case  it  fails. 

In  the  fibrosderotic  (stricture-forming)  tuberculosis  the  irrigating 
treatment  alone  or  in  connection  with  entero-anastomosis  has  the 
same  indications  as  in  the  hyperplastic  type. 

Glandular  and  peritoneal  tuberculosis  are  benefited  b\'  enterochsis 
as  independent  affections,  and  also  when  they  are  associated  with 
bowel  tuberculosis.  The  author  has  shown  by  statistics  that  there  is 
always  a  simple  or  specific  catarrhal  inflammation  of  the  mucosa  in 
persons  who  suffer  from  phthisis,  infection  of  other  organs,  or  intes- 
tinal tuberculosis,  therefore  irrigation  is  beneficial  in  these  cases 
because  it  attenuates  or  pre\"ents  the  lodgment  of  swallowed  bacilli, 
soothes  and  heals  the  bowel,  minimizes  auto-intoxication,  improves 
the  circulation,  and  increases  nutrition  when  oils  or  nutrient  solutions 
are  employed. 

'■  Gant,  Constipation  and  Intestinal  Obstruction,  pp.  415,  416. 


28o     TUBERCULAR    ENTERITIS.    COLITIS.    ENTEROCOLITIS.    DIARRHEA    IN 

The  irrigants  used  in  the  treatment  of  tubercular  are  practically 
the  same  as  for  other  t\pes  of  colitis.  The  chief  benefit  derived  from 
irrigating  solutions  is  attributable  to  their  mechanic  effect  in  cleansing 
the  inflamed  mucosa  and  ulcers,  areas  of  bacteria,  toxins,  acrid  dis- 
charges, putrefying  food  remnants,  and  feces. 

Cold  solutions  (55°  to  75°  F.)  induce  discomfort  and  enterospasm, 
while  hot  ones  (100°  to  115°  F.)  soothe  the  gut,  diminish  soreness,  and 
relieve  this  condition. 

When  the  stools  are  numerous,  bleeding  is  profuse,  and  the  patient 
is  being  exhausted  by  the  diarrhea,  irrigations  of  silver  nitrate,  gr.  xxx 
to  Oij  (2-1000),  are  administered  three  times  weekly,  after  which 
the  bowel  is  washed  out  with  a  normal  salt  solution  to  remove 
any  excess  of  siher.  When  the  evacuations  have  been  considerably 
reduced  and  the  patient  feels  better,  one  of  the  following  milder  solu- 
tions should  be  substituted  for  the  silver,  viz.:  boric  acid.  3  per  cent.; 
ichthyol.  i  to  2  per  cent. ;  balsam  of  Peru,  i  per  cent. :  permanganate  of 
potassium,  i  per  cent.;  silver  nitrate,  gr.  v  to  Oij  (0.30-1000);  protar- 
gol  or  argvrol.  5  per  cent. — irrigants  the  strength  of  which  may  be 
slightly  increased  or  decreased  according  to  the  severity  of  the  ulcer- 
ation and  consequent  diarrhea. 

Very  often  the  treatments  are  best  alternated  with  warm  olive, 
cotton-seed,  or  mineral  oil  injections,  alone  or  containing  bismuth, 
aristol.  salol.  salic>late  of  soda,  morphin,  etc..  which  soothe  the 
mucosa,  protect  and  heal  ulcers,  lessen  putrefation,  or  partially  dis- 
infect the  bowel. 

A  description  of  the  different  ways  of  irrigating  the  colon  and 
small  intestine  and  administering  enemata  has  been  given  in  detail 
in  Chapter  XLI  devoted  to  the  purpose,  and  a  repetition  would  be  out 
of  place  here. 

Topical  Applications. — Formerly,  topical  applications  were  made 
through  a  speculum  and  limited  to  the  lower  rectum,  but  with  the  aid 
of  the  sigmoidoscope,  applicators,  and  reflected  light  one  can  locate 
and  treat  lesions  located  in  the  lower  sigmoid  flexure  and  all  parts 
of  the  rectum  (Figs.  40.  41). 

In  aggravated  cases  of  intestinal  tuberculosis  (different  types) 
where  there  are  large  single  or  multiple  sluggish  ulcers  which  do  not 
respond  to  medicated  irrigations,  much  can  often  be  done  to  hasten 
the  patient's  recoven,-  by  dieting  and  measures  recommended  for 
upbuilding  the  general  health,  and  topical  applications  made  to 
ulcers,  the  inflamed  mucosa,  or  both. 

Persistent  lesions  heal  faster  when  cauterized  with  an  electric  or 
Paquelin  cauter\-.  but  some  patients  object  to  them,  in  which  case  a 
silver  nitrate  or  copper  sulphate  solution  (full  strength)  should  be 
substituted  and  applied  by  means  of  cotton  on  an  applicator  intro- 
duced through  a  sigmoidoscope,  while  care  is  being  taken  to  keep 
the  solution  from  coming  in  contact  with  the  mucosa  between  the 
lesions. 

When   the   ulcers   take  on  a   healthier   appearance   and    for   less 


TOPICAL    APPLICATIONS 


281 


obstinate  lesions,  ichthyol  and  glycerin  or  the  balsam  of  Peru,  50 
per  cent.,  are  preferable  to  strong  silver  and  copper  solutions.  Nitric 
and  other  acids  accomplish  less  and  should  not  be  emjiloyed,  because 

it  is  difficult  to  prevent  them  from 
-s^  ^■^-r'35r  "W^BBPI  spreading  from  diseased  to  healthy 

tissues,   where    they  cause  slough- 
ing. 

In  the  average  case,  or  where  one 
has  to  deal  with  superficial  lesions 
or  those  having  a  tendency  to  heal, 
silver  nitrate,  6  per  cent.,  protargol, 
20  per  cent.,  balsam  of  Peru,  25  per 
cent.,  or  ichthyol,  15  per  cent.,  give 
satisfactory  results  when  applied  to 
the  lesions  three  times  weekly  and 
the  bowel  is  irrigated  on  alternate 
days.  Now  and  then  stimulating  ap- 
plications make  the  patient  worse, 
in  which  case  the  lesions  and  ad- 


Fig.  40. — Chronic  tuberculosis  of  the 
anorectal  region  compHcatcd  by  ulcera- 
tion, abscess,  fistula,  perforation,  and  the 
formation  of  varjang  shaped  and  sized 
ridges  of  scar-tissue  from  healed  lesions.' 


Fig.  41. — Tubercular  ulceration  of  rectum.* 


jacent  mucosa  should  be  treated  with  methylene-bkie,  10  per  cent.,  a 
remedy  of  the  highest  value  in  the  treatment  of  all  chronic  ulcers. 
Where  the  mucosa  is  inflamed  and  eroded  from  the  discharge,  burn- 
ing pain  and  tenderness  can  be  diminished  by  mopping  the  ulcerated 
r-ctal  mucous  membrane  with  cocainized  oil  or  that  containing  l^smuth 

'Army  Med.  Museum. 


282      TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

or  aristol,  which  form  a  coating  over  and  protect  it  from  irritation  by 
the  feces. 

Where  there  are  no  ulcers  and  the  patient  suffers  from  a  simple 
catarrhal  or  a  tubercular  sigmoido proctitis,  his  condition  can  be 
greatly  improved  by  introducing  the  sigmoidoscope  and  inflating  the 
bowel  with  boric  acid  or  a  powder  composed  of  the  following: 

I^.     Tannic  acid OSS  (2.0); 

Bismuth  subnitrate gr.  xx  (1.3); 

Pulv.  alum 3 ss  (2.0) ; 

Pulv.  talcum 5 J  (30.0).— M. 

Sig. — Insufflate  the  bowel  daily. 

In  case  the  intestine  is  inflamed,  sensitive,  and  marked  by  pin- 
point ulcers,  the  author  has  found  the  accompanying  formula  very 
useful : 

I^.     Nosophen  ^ 

Dermatol    V aa  3ij  (8.0).— M. 

Orthoform  j 
Sig. — Insufflate. 

Where  the  patient  is  nervous  and  complains  of  extreme  pain  from 
topical  or  other  treatment,  his  suffering  can  be  reduced  by  spraying 
or  swabbing  the  mucosa  with  cocain,  8  per  cent.,  but  the  solution 
should  not  be  injected,  as  a  dangerous  amount  will  be  cjuickly  ab- 
sorbed. 

Having  given  the  medical,  the  author  will  now  discuss  the  serum 
and  vaccine  treatment  of  intestinal  tuberculosis,  alone  and  when  com- 
plicated by  lung  involvement. 

Serum  Treatment. — Various  sera,  including  Koch's  old  and  new 
tuberculins  and  bacillary  emulsions  and  vaccine  preparations,  have 
been  employed  in  the  prophylactic  treatment  of  general  and  tubercu- 
losis of  the  intestine,  but  the  results  have  not  been  particularly  flat- 
tering. Thus  far  they  have  not  proved  useful  in  the  treatment  of  foci 
in  the  bowel  which  causes  acute  or  chronic  diarrhea,  and  injections 
of  them  have  occasionally  been  followed  by  serious  toxic  manifesta- 
tions and  abscess. 

Maragliano  has  produced  a  serum  (cows')  for  which  he  claims 
much  when  employed  as  a  vaccine  to  immunize  the  patient  and  as 
a  therapeutic  measure  to  cure  tuberculosis.  Of  the  many  cases 
treated  with  his  serum  in  Italy  there  were  250  incipient  cases  where 
the  lesions  were  circumscribed  and  there  was  no  fever,  of  whom  38 
per  cent,  were  cured  and  50  per  cent,  greatly  improved,  but  at  the 
Phipps  Institute  this  serum  was  given  a  thorough  trial  and  proved 
unreliable  in  old,  and  of  no  more  value  in  incipient,  cases  than  if  the 
patient  had  been  subjected  to  the  Trodeaus  or  sanitarium  treatment. 
Marmorek's  horse  serum  has  exhibited  a  tendency  to  immunize  and 
improve  the  condition  of  tubercular  animals,  l)ut  in  man  the  good 
results  have  not  been  sufficient  to  offset  its  toxic  effects. 


SERUM    TKKATMEXT  283 

It  has  been  shown  repeeitedly  that  the  index  is  hnvt-rt-d  ni  tul)er- 
cular  sul)jects  when  regions  of  the  foci  are  traumaiized.  Conse- 
quenil\',  the  achiiinistration  of  Koch's  new  tul)ercuHn  R.  (which 
is  macie  of  disintegrated  baciUi)  and  similar  preparations  are  waluable 
aids  in  the  diagnosis  of  intestinal  tuberculosis,  since  their  employment 
is  indicated  by  a  rise  of  the  opsonic  index  and  the  treatment  is 
accompanied  by  increase  in  the  opsonins  which  are  antagonistic  to 
tubercle  bacilli. 

The  hygienic,  dietetic,  and  medicinal  treatment  of  peritoneal  tuber- 
culosis is  the  same  as  when  the  gut  is  affected,  but  non-surgical  and 
operative  therapeutic  measures  must  be  selected  according  to  indica- 
tions. Some  patients  do  well  under  colonic  irrigation  when  they  are 
kept  quietly  in  bed,  given  a  light  nutritious  diet,  cold  ajjplications 
are  made  to  the  abdomen,  and  the  rapid  pulse,  high  temperature,  con- 
stipation, diarrhea,  and  other  manifestations  are  symptomatically 
treated. 

The  surgical  measures  most  often  resorted  to  in  tubercular  peritonitis 
are  aspiration,  laparotomy,  and  excision  of  abdominal  tubercular  foci. 
The  first  is  applicable  when  ascites  is  marked,  but  is  often  unsatis- 
factory because  the  operation  must  be  repeated  and  there  is  danger 
of  injuring  the  intestine  with  aspirating  needle  or  trocar.  Laparotomy 
is  not  dangerous  and  gives  the  best  results,  but  no  satisfactory^  explana- 
tion has  been  advanced  as  to  why  a  cure  sometimes  follows  this  pro- 
cedure. It  may  be  due  to  relieving  distention,  permitting  the  escape 
of  retained  toxins,  admitting  light  or  air  to  the  abdominal  ca\ity, 
mechanical  irritation  to  the  peritoneum,  effect  upon  the  nerves  through 
psychic  impulses,  excitement  brought  about  by  the  preparation  for 
operation  and  after-treatment  which  encourages  the  patient  to  believe 
that  he  will  be  cured,  or  some  other  unknown  cause.  While  the  abdo- 
men is  opened,  complicating  adhesions  should  be  broken  up,  rents  in 
the  viscera  should  be  repaired,  and  tubercular  deposits  excised  when 
feasible.  According  to  Treves  and  others,  about  one-third  of  the 
patients  who  suffer  from  tubercular  peritonitis  are  curable  and  many 
others  are  improved  by  laparotomy.  Xo  doubt  man\-  of  these  patients 
remain  well,  but  the  author's  experience  would  lead  him  to  expect  a 
relapse  in  a  goodly  percentage  of  the  cases. 

The  dose  of  new  tuberculin  is  toVo  to  irio  mg.,  but  must  be  \aried 
and  administered  at  shorter  or  longer  intervals,  according  to  the 
opsonic  indices.  It  is  not  advisable  to  prescribe  a  large  amount  and 
make  the  injections  frequently.  In  fact,  one  treatment  should  not 
follow  another  until  the  symptoms  of  the  former  have  subsided,  other- 
wise the  remedy  instead  of  helping  may  have  a  contrar},-  effect  upon 
the  patient.  The  administration  should  be  discontinued  when  the 
toxic  effect  of  the  tuberculin  becomes  annoying  or  dangerous,  and  dis- 
continued when  the  patient  becomes  tolerant  of  it. 

Naturally,  the  sera  act  more  fa\-orably  in  incipient  than  in  aggra- 
vated cases  of  tuberculosis  where  intestinal  or  other  lesions  are  ex- 
tensive and  there  are  suppurating  areas.     Concerning  the  tuberculin 


284     TUBERCLXAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

treatment,  Koehler  and  Lenzmann  say:  "In  a  general  way  it  may  be 
said  that  the  initial  stages  of  tuberculosis  are  preferably  subjected  to 
treatment  with  old  tuberculin,  whereas  the  advanced  and  especially 
the  ver\'  chronic  cases  are  more  amenable  to  the  tubercle  bacilli 
emulsion.  Certain  precarious  cases,  which  do  not  readily  tolerate 
old  tuberculin,  and  react  to  every  injection  with  persistent  and  high 
fever,  should  be  treated  by  means  of  tuberculin  T.  R.  or  the  mild  prep- 
arations from  germ-free  tubercle  bacilli  bouillon." 

From  the  writer's  experience  and  his  perusal  of  the  literature  con- 
cerning sera  and  vaccine  therapy,  he  believes  them  worthy  of  a  trial 
when  the  process  is  in  the  incipient  stage,  and  as  an  immunizing  agent 
in  persons  of  an  inherited  predisposition  to  tuberculosis,  but  considers 
them  of  but  ver\-  little  value  in  the  treatment  of  fully  developed  foci 
in  the  intestine,  and  particularly  when  complicated  by  lung  involve- 
ment, and  advises  against  their  use  because  of  their  tendency  to  pro- 
duce unpleasant  or  toxic  symptoms  and  abscess  which  may  result 
fatally. 

From  what  has  been  attained  in  the  prevention  and  treatment 
of  diphtheria,  typhoid  fever,  syphilis,  small-pox,  and  other  infectious 
diseases,  and  favorable  cases  of  tuberculosis  by  sera,  vaccines,  etc., 
the  chances  are  that  before  long  an  agent  will  be  discovered  that  will 
prevent  or  cure  tuberculosis  of  the  lungs,  intestine,  and  elsewhere. 


CHAPTER   XXIV 

TUBERCULAR   ENTERITIS,  COLITIS,   AND  ENTEROCOLITIS 
INTESTINAL  TUBERCULOSIS  ,  DIARRHEA  IN    Concluded^ 

SURGICAL  TREATMENT 

Surgical  intervention  is  indicated  in  bowel  tuberculosis  (colitis) 
when  the  various  measures  already  recommended  for  the  relief  and 
cure  of  this  affection  fail,  when  the  type  of  infection  is  \-irulent,  and 
the  local  lesions  progress  rapidly  or  profoundly  influence  the  patient's 
general  health,  when  dangerous  bleeding  takes  place  and  the  patient 
suffers  frequently  and  greatly  from  cramps,  or  his  strength  is  being 
rapidly  exhausted  because  of  the  frequent  movements,  and  in  chronic- 
ally aggravated  cases  complicated  by  stricture,  abscess,  fistula,  and 
peritonitis  from  perforation. 

Surgical  intervention  is  not  always  satisfactory  in  the  treatment 
of  tubercular  colitis  and  diarrhea  because  the  ulcers  often  heal  slowly 
or  extend,  owing  to  the  subject's  lowered  resistance  consequent  upon 
his  lack  of  appetite,  poor  digestion,  bad  assimilation,  and  debilitated 
condition. 

Except  in  urgent  cases  the  author  never  suggests  an  operation 
in  this  class  of  cases  until  he  has  first  made  a  thorough  general  and 
local  examination,  endeavored  to  build  the  patient  up  by  a  proper 
diet,  having  him  spend  his  time  in  the  fresh  air,  giving  him  tonics  and 
colonic  irrigations. 

One  should  operate  as  quickly  for  the  relief  of  one  t>"pe  of  intes- 
tinal tuberculosis  as  another,  and  for  any  dangerous  complication 
which  might  arise  if  the  patient  has  sufficient  strength,  but  when  he  is 
debilitated,  or  going  to  die  shortly  from  foci  in  the  lungs  or  elsewhere, 
nothing  can  be  accomplished  by  operation.  Most  patients  suffering 
from  bowel  tuberculosis  have  an  active  or  latent  infection  in  the  lung, 
a  condition  which  under  favorable  circumstances  may  be  aggravated 
by  the  other  and  terminate  fatally.  Because  of  this  the  author  oper- 
ates under  local  anesthesia,  but  uses  gas  or  gas-oxygen  when  general 
narcosis  is  required. 

Surgical  procedures  designed  for  the  treatment  of  bowel  tubercu- 
losis have  for  their  object  one  of  three  things — removal  of  the  disease, 
putting  the  gut  at  rest,  or  providing  for  through-and-through  irri- 
gation. 

Extirpation  of  tubercular  foci  is  accomplished  by  enterectomy, 
cecectomy,  sigmoidectomy,  or  proctectomy,  according  to  the  location  of 
the  disease. 

285 


286     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

Exclusioti  (short-circuiting)  of  the  diseased  intestine  is  accomplished 
by  lateral  entero-anastomosis  (Maisonneuve)  -or  unilateral  or  bilateral 
exclusion,  and  bowel  flushing  is  achieved  by  means  of  enterostomy 
(duodenostomy,  jejunostomy,  ileostomy),  appendicostomy,  cecostomy, 
appendiceal  cecostomy,  cecostomy  with  an  arrangement  for  irrigating 
large  and  small  intestines  (Gant's),  and  colostomy. 

When  the  patient's  condition  permits,  resection  is  the  operation  of 
choice,  because  it  offers  the  patient  the  best  chance  for  a  quick  and 
permanent  recover^-.  While  it  cannot  be  denied  that  this  class  of 
patients  withstand  operation  as  well  as  those  afflicted  with  other 
intestinal  affections,  it  must  be  admitted  that  the  procedure  is  always 
fraught  with  some  danger  because  of  the  time  required,  intestinal 
trauma,  and  injun,'  to  adjacent  organs  incident  to  the  destroying  of 
adhesions  and  freeing  the  gut.  The  experience  of  the  author  is  in 
harmony  with  that  of  other  operators,  in  that  the  danger  is  about  the 
same  whether  a  small  or  large  piece  of  intestine  is  excised.  He  has 
treated  patients  where  several  inches  or  feet  of  the  large  or  small  intes- 
tine were  removed  who  suffered  but  little  from  shock  and  made  an  un- 
interrupted recovery.  Multiple  resections  are  necessary  where  widely 
separated  segments  of  gut  are  diseased  and  when  tubercular  foci 
develop  subsequent  to  operation.  Instances  of  such  cases  will  be 
found  in  the  statistics  given  below. 

The  author  has  at  times  found  it  advantageous  to  short-circuit  and 
put  the  diseased  bowel  at  rest,  or  perform  appendicostomy  or  cecos- 
tomy as  a  preliminan,'  step  to  resection  when  the  patient's  condition 
would  not  warrant  a  more  radical  operation. 

Next  to  resection,  short-circuiting  is  the  favored  procedure  in  this 
class  of  cases.  Intestinal  exclusion  consists  in  diverting  the  fecal 
current  from  a  large  or  small  part  of  the  bowel,  so  that  the  lesions 
within  it  may  obtain  rest  and  heal.  The  author  has  resorted  to 
exclusion  only  six  times  in  treating  intestinal  tuberculosis,  but  has 
practised  it  with  satisfaction  many  times  for  the  relief  of  other 
conditions,^  and  the  operation,  with  few  exceptions,  has  not  proved 
tedious,  difficult,  or  dangerous. 

A  segment  of  the  intestine  may  be  excluded  (a)  by  simple  entero- 
anastomosis  with  a  Murphy  button  or  suture  (Fig.  176);  (b)  by  closing 
the  bowel  on  one  side  of  the  lesion  and  anastomosing  the  proximal 
end  with  healthy  bowel  below — unilateral  exclusion  (Fig.  181);  and  (c) 
by  dividing  the  intestine  on  both  sides  of  the  diseased  area  and  join- 
ing or  closing  the  proximal  and  distal  ends — bilateral  exclusion  (Fig. 

Of  the  three  procedures,  the  former  is  usually  practised  in  bowel 
tuberculosis.  When  doing  either  of  these  operations  the  writer  usually 
provides  a  way  (appendicostomy  or  cecostomy,  etc.)  of  flushing  the 
diseased  bowel  to  relieve  the  excluded  gut  of  backed-up  feces  and 
discharges,  and  thus  treat  the  lesions.  It  is  really  necessan,-  to  short- 
circuit  the  small  intestine  because  in  the  majority  of  cases  tubercular 
^  Gant,  Constipation  and  Intestinal  Obstruction,  p.  410. 


SURGICAL    TREATMENT  287 

lesions  are  located  in  the  cecal  region  or  the  rectum,  and  when  called 
tor  it  is  advisable  to  connect  the  proximal  end  of  the  small  with  the 
distal  end  of  ilie  large  gut.  Under  such  circumstances  the  movements 
are  fluid  and  frequent  at  first,  but  in  a  short  time  the  ileum  gradually 
takes  upon  itself  the  functions  of  the  colon,  and  the  stools  become 
fewer  and  more  solid  week  by  week,  until  by  the  end  of  two  or  three 
months  they  usually  become  normal  in  number,  form,  and  consistence. 

Entero-anastomosis  may  also  be  called  for  as  a  preliminary  measure 
to  excision  in  aggravated  cases,  and  following  this  operation  when 
there  is  a  resultant  stricture.  The  flattering  results  which  follow  these 
methods  of  excluding  the  diseased  bowel  have  been  verified  b\  the 
author,  and  are  shown  in  the  appended  statistical  tables. 

These  procedures  (entero-anastomosis  and  unilateral  and  bilateral 
exclusion)  are  indicated  when  there  are  complications  requiring  im- 
mediate attention  in  the  presence  of  serious  lung  involvement,  when 
the  patient  is  greatly  debilitated  or  exhausted,  the  bowel  is  extensively 
diseased,  or  a  neoplastic  tubercular  tumor  is  large  and  adherent 
everywhere,  numerous  adhesions  which  ma\  bind  the  affected  fragile 
segment  to  the  intestinal  or  other  organs,  when  there  are  chronic 
pyostercoral  fistula,  extensive  glandular  involvement,  and  when,  for 
any  reason,  extirpation  is  out  of  the  question,  or  it  has  been  performed 
and  the  disease  has  returned  or  stenosis  has  followed. 

The  iinfavorahle  features  of  intestinal  exclusion  are:  it  is  more  often 
palliative  than  curative,  healing  takes  place  slower  than  following 
extirpation,  the  discharge  and  bacilli  continue  to  pour  down  over 
healthy  gut,  the  secretions  and  feces  sometimes  back  up  and  become 
stagnated,  no  provision  is  made  for  the  direct  treatment  of  the  lesions, 
the  disease  may  attack  the  anastomotic  opening  and  recjuire  a  second 
operation,  no  attempt  is  made  to  correct  or  remove  peri-intestinal 
adhesions,  abscesses,  fistulse,  and  diseased  glands  causing  the  patient 
discomfort,  foci  are  left  from  which  the  disease  may  extend  or  become 
generalized,  and  he  must  necessarily  suffer  for  several  weeks  from  diar- 
rhea until  the  feces  once  more  become  firm. 

Throiigh-and-through  irrigation  (by  way  of  a  cecal  or  appendiceal 
opening)  is  always  indicated  in  persons  who  have  intestinal  tubercu- 
losis and  suffer  severely  from  exhausting  diarrhea,  bacterial  and 
chemical  toxins,  bleeding,  irritation  and  tenesmus  incited  by  acrid 
discharges,  gas  accumulations  or  cramps  incident  to  fermentation  or 
putrefying  food  within  the  intestine,  when  enteroclysis  from  below 
does  not  accomplish  the  desired  results.  In  some  instances  all  the 
infected  foci  are  located  in  the  lower  sigmoid  flexure  and  rectum,  and 
under  these  conditions  flushing  the  bowel  through  the  anus  usually 
proves  effective  because  the  fluid  reaches  them;  but,  on  the  contrary, 
when  the  inflammation  or  ulcers  extend  throughout  the  large  bowel 
irrigation  from  below  often  fails  because  the  solution  does  not  reach 
all  the  segments  of  the  diseased  colon  on  account  of  the  patient's 
I^osition,  type  of  irrigator  employed,  or  the  irrigating  tube  curls  up  in  the 
rectum  or  sigmoid  flexure  and  prevents  the  solution  from  flowing  into 


288     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

the  upper  colon,  lender  such  circumstances  an  artificial  inlet  should 
be  established  b>'  appendicostomy  (Fig.  42),  cecostomy  (Fig.  159), 
appendiceal  cecostomy,  the  author's  cecostomy,  by  means  of  which  the 
large  and  small  bowel  can  be  separately  or  simultaneously  flushed,  or 
colostomy.  These  procedures,  with  the  author's  cecostomy,  may  be 
employed  in  the  treatment  of  tuberculosis  involving  all  or  a  part  of 
the  colon,  but  they  (with  the  exception  of  the  author's  cecostomy, 
Fig.  159)  are  not  satisfactory  when  there  is.  enterocolitis  because  the 
solution  cannot  be  made  to  pass  the  ileocecal  valve,  and  his  operation 
should  be  performed,  since  it  provides  for  thorough  irrigation  of  both 
the  large  and  small  intestine. 

While  throiigh-and-throiigh  irrigation  (Fig.  42)  is  beneficial  in 
all  varieties  of  intestinal  tuberculosis,  its  palliative  and  curative  effects 
are  decidedly  more  marked  in  the  enteric  form  of  tuberculosis  which 


Fig.  42. — Through-and-through  irrigation  following  the  author's  appendicostomy. 


involves  the  mucosa  superficially  than  in  either  the  enteroperitoneal, 
which  attacks  all  the  intestinal  coats  from  within  and  without;  the 
hyperplastic,  wherein  there  is  extensive  tumor  formation  and  ulcera- 
tion in  the  later  stages;  the  stenotic,  where  the  tunics  are  converted  into 
fibrous  tissue;  the  glandular,  with  inflamed  and  caseating  lymph-nodes; 
or  the  peritoneal  types. 

There  is  a  catarrhal  or  tubercular  inflammation,  erosion,  or  ulcera- 
tion of  the  mucosa  in  all  forms  at  one  stage  or  another  of  the  disease, 
conditions  invariably  improved  or  cured  when  the  bowel  is  properly 
irrigated  daily  or  three  times  weekly  with  one  of  the  irrigants  already 
mentioned. 

Through-and-through  irrigation  is  preferable  to  the  introduction 
of  a  solution  from  below  because  larger  amounts  and  stronger  solu- 
tions can  be  used,  owing  to  the  fact  that  they  pass  rapidly  through 
the  gut,  particularly  when  a  small  proctoscope  has  been  introduced 


CECECTOMY  AND  ILEOCECECTOMY 


289 


through  which  they  may  escape.  Less  pain  accompanies  this  pro- 
cedure than  the  former,  for  the  reason  that  the  fluid  flows  in  and  out 
in  a  continuous  stream,  l)in  when  ii  is  injected  through  the  anus  there 
is  considerable  distention  pain  b\-  the  time  the  necessary  amount  of 
fluid  has  been  introduced. 

The  above-named  operations  have  occasionally  been  employed 
as  a  preliminary'  treatment  to  heal  ulcers  and  improve  the  patient's 
general  condition  prior  to  extirpation  or  resection,  and  in  conjunction 
with  intestinal  exclusion  to  prevent  stagnation  and  favor  a  more 
speedy  convalescence  through  cleansing  of  the  lesions. 

The  irrigants  employed  in  this  more  complete  method  of  entero- 
cK-sis  have  already  been  given  or  will  be  discussed  in  the  chapter 
which  deals  with  intestinal  irrigation.  The  author  has  not  pointed 
out  the  special  features  and  methods  of  performing  the  operations 
of  excision,  exclusion,  appendicostomy,  cecostomy.  and  colostomy 
here,  because  their  indications  and  technic  have  been  given  in  the 
chapters  set  apart  for  the  surgical  treatment  of  diarrhea. 

In  concluding  the  treatment  of  intestinal  tuberculosis  nothing 
more  is  necessary  than  to  summarize  the  statistical  results  of  the 
above-mentioned  operations  and  point  out  their  relative  value  under 
var>'ing  circumstances. 

STATISTICS    CONCERNING    ENTERECTOMY.   CECECTOMY,    COLECTOMY,   AND 

PROCTECTOMY 

Cecectomy  and  Ileocecectomy. — Under  this  heading  are  grouped 
the  statistics  relati\-e  to  extirpation  of  the  cecum,  lower  ileum,  prox- 
imal end  of  the  ascending  colon,  and  the  appendix,  alone  or  together. 

ILEOCOLECTOMY 


Author. 


Personal  and 
collected  cases. 


Mortality. 


Cures. 


Campiche  (1905) 

Campiche  (1900-1905) 

Conrath  (1898) 

Fiori 

Prague  Surgical  Clinic  (Rubesch) . 

Eschenbach 

Brunner 

Hartmann 

Nikoljski 

Bemay 

Lotheissen 

Nicoloysen 

Caird 

Gant 


Total. 


Average  mortality. 
Average  cures 


154 

50 
60 

7 
12 

24 
125 
128 

37 
17 
47 


67s 


565 
283 


Per  cent. 
12.0 


14.2 

8.3 
29.1 
25.0 
21.8 

31.0 

13-5 
17.6 
19.1 
36.3 
33-3 


21.8 

46.4 


Per  cent. 
41.0 
30.0 
31.6 
71.0  (2  yrs.) 
58.3 


19 


290     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 
INTESTINAL  EXCLUSION 

ENTERO-ANASTOMOSIS,   UNILATERAL   AND   BILATERAL  EXCLUSION 


Author. 

Personal  and 
collected  cases. 

Mortality. 

Results. 

Rubesch 

13 

31 

4 

15 
49 

10 
13 

4 

36 
3 

Per  cent. 

7.69 

9.67 

25.00 

26.60 
20.40 

38.4 

8.33 

Hartmann 

Bernay 

3   patients  recovered;    i   well 
two  years  later. 

65.3  per  cent,  lived  one  year 

or  more. 
Immediate    and    remote    re- 

Lotheissen  

Nikoljski 

Conrath 

Halberer 

Fiori 

Brunner 

Gant 

sults  excellent. 
8  patients  lived  ele\en  months 

to  five  years. 
75    per    cent,    survived    after 

three  years. 

Still    living,   eleven    months, 
two  years,  and  three  years. 

Total 

178 

13.60 

OPERATIVE  TREATMENT  OF  INTESTINAL  TUBERCULOS'lS 


Author. 

Nature  of  operation. 

Number  of 
cases. 

Deaths. 

Percentage  of 
mortality. 

Hartmann 
(Groves) : 

Partial  resection  of  cecum 

Resection  with  end-to-end  an- 
astomosis   

Resection  with  side-to-side  an- 
astomosis   

Resection  a  Deux  temps 

Ileocolostomy 

Unilateral  exclusion 

Bilateral  exclusion 

End-to-side  (anastomosis) 

Multiple  operations 

Total  and  average  percentage . 

9 
78 

31 
10 
29 

9 

22 

19 

22 

I 
19 

5 
3 
4 
I 

2 

3 
8 

II 

24 

16 

33 
14 
II 

9 
IS 
36 

229 

46 

20 

Conrath : 

Resection 

Resection  of  intestinal  wall     .  . 
Entero-anastomosis 

58 

6 

10 

II 
2 

19 

Enucleations 

Exploratory  laparotomy 

8 
4 

25 

Total  and  average  percentage . 

86 

13 

IS 

CFXPXTO.MY    AND    ILKOCIXECTOMY 


291 


OPERATIVE   TKEAT.MEXT    OF    INTESTINAL    STENOSES 


Nicoloysen 


Resection 

Entero-anastomosis 

Pyloropla>ty 

Enterostomy 

Laparotomy 

Total 


Number  of 
cases. 


47 

49 

6 

I 

7 


Mortality. 


Per  cent. 
19.I 
20.4 


Mortality 
within 


Per  cent. 
34-7 


Multiple  stenoses:  52  out 
of  1 10  cases. 


Number  of 
cases. 


32 


Mortality. 

Per  .cent. 
43-7 


In  ihe  above  tables,  together  with  those  of  Conrath  and  Hart- 
mann  quoted  by  Groves,  and  Brunner's  statistics,  the  mortaUty  and 
percentage  of  recoveries  are  fairly  well  shown.  From  the  author's 
personal  experience,  the  statistics  given,  and  an  analysis  of  the  opin- 
ions of  prominent  surgeons  concerning  the  operative  treatment  of 
tuberculosis  and  the  relative  values  of  the  different  procedures,  he  has 
drawn  the  following  conclusions: 

(i)  The  mortality  of  operations  performed  for  the  relief  of  intes- 
tinal tuberculosis  appears  high  and  the  results  not  very  good,  but,  when 
one  takes  into  consideration  the  condition  of  the  average  tubercular 
subject,  the  fact  that  until  within  a  few  years  all  of  these  patients  died, 
and  that  the  mortality  from  them  is  but  slightly  if  any  greater  than 
for  the  same  procedures  done  for  non-tubercular  lesions,  he  realizes 
that  considerable  progress  has  been  made  in  the  surgical  treatment  of 
intestinal  tuberculosis. 

(2)  Neoplastic  tuberculosis  is  practically  always  encountered 
at  the  ileocecal  region,  and  in  the  operative  statistics  it  was  found 
but  once  elsewhere  above  the  rectum,  and  that  was  at  the  juncture 
of  the  transverse  and  descending  colons. 

(3)  Hyperplastic  or  ileocecal  tuberculosis  is  a  purely  surgical 
affection,  and  the  results  following  resection  of  the  diseased  gut  are 
splendid  and  obtained  with  comparatively  little  danger. 

(4)  The  mortality  following  resection  of  tubercular  tumors  is 
much  less  than  after  other  types  of  tuberculosis. 

(5)  The  high  mortality  (30  per  cent.)  which  formerly  prevailed 
in  this  type  of  resection  should,  with  our  present  knowledge  and  tech- 
nic,  be  about  10  per  cent. 

(6)  Exclusion  (usually  entero-anastomosis)  is  indicated  in  h\-pcr- 
plastic  tuberculosis  when  there  is  extensive  lung  involvement,  the 
patient  is  greatly  debilitated  or  exhausted  from  diarrhea,  when  the 
tumor  is  very  large  and  bound  down  by  extensive  adhesions,  or  com- 
plicated by  abscess  or  fistula — conditions  which  make  resection  ex- 
tremely dangerous. 


29-2     TUBERCULAR    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

(7)  Unilateral  and  bilateral  exclusion  usually  temporarily  or  com- 
pletely relieve  the  most  distressing  manifestations  of  the  disease,  and 
cause  the  neoplasm  to  shrink  up  or  effect  its  permanent  disappearance. 

(8)  From  the  frequency  with  which  ileocecal  tubercular  tumors  are 
encountered  and  cured  it  is  quite  evident  that  they  were  formerl\- 
mistaken  for  carcinoma,  and  surgeons  declined  operation  because  of 
their  size  and  connections.  Certainly  the  records  of  a  decade  ago  show 
but  comparatively  few  cecal  excisions  for  the  relief  of  tubercular  tumor 
formations. 

(9)  There  is  less  danger  from  lung  complications  in  this  than  other 
types  of  tuberculosis,  because  the  infection  is  primary  and  less  viru- 
lent. 

(10)  Results  are  very  much  better  when  the  swelling  or  ulcerated 
areas  are  diagnosed  and  promptly  removed  than  after  the  infection 
has  been  permitted  to  extend  to  other  segments  of  the  intestine. 

(11)  Entero-anastomosis  (Maisonneuve),  unilateral  and  bilateral 
exclusion,  were  formerly  regarded  as  palliative  measures,  but  today 
they  are  considered  a  curative  power,  and  some  operators  say  they 
are  preferable  to  resection  in  rhost  instances. 

(12)  Entero-anastomosis  is  the  procedure  of  choice  when  the  tuber- 
cular process  extensively  involves  the  small  and  large  bowel  and 
excision  of  the  diseased  segment  is  impracticable,  and  should  be  sub- 
stituted for  resection  w^hen  the  patient  is  unable  to  withstand  a  pro- 
longed operation. 

(13)  Convalescence  following  exclusion  is  longer  than  after  suc- 
cessful extirpation  of  the  tubercular  foci. 

(14)  In  hyperplastic  or  ileocecal  tuberculosis,  where  the  disease 
is  localized  and  possibly  primary,  excision  is  preferable  to  anastomosis 
except  under  the  above-named  conditions. 

(15)  Complications  are  fewer  and  the  results  better  when  short-cir- 
cuiting is  reinforced  by  enterostomy,  appendicostomy,  cecostomy,  or 
temporary  colostomy,  so  that  the  diseased  bowel  can  be  cleansed  of 
feces  and  discharges. 

(16)  Entero-anastomosis  of  the  proximal  with  the  distal  gut  puts 
the  affected  area  at  rest  and  favors  healing  of  the  lesions,  while 
excision  eliminates  it  altogether. 

(17)  Short-circuiting,  when  the  ileum  is  joined  to  the  sigmoid 
flexure  or  rectum  (ileorectostomy),  is  followed  by  frequent  movements 
for  several  weeks,  or  until  the  lower  ileum  begins  to  take  upon  itself 
the  work  of  the  colon,  when  the  stools  become  normal  in  number  and 
consistency. 

(18)  The  low  mortality  follow^ing  bilateral  exclusion  is  partially 
offset  by  the  annoying  fistula  left  to  drain  the  diseased  intestine. 

(19)  The  chief  objection  to  entero-anastomosis  and  unilateral  ex- 
clusion in  the  treatment  of  tuberculosis  is  that  the  diseased  area  is 
left,  and  nothing  is  done  to  prevent  the  bacilli  and  irritating  discharges 
from  pouring  into  the  healthy  bowel  below. 

(20)  Bilateral    exclusion    in    inoperable  cases  and  where  fistula  is 


CECECTOMY  AND  ILEOCECECTOMY  293 

present  is  superior  to  the  other  forms,  because  the  gut  is  closed  above 
and  below  the  foci  and  the  intestinal  contents  cannot  reach  them,  nor 
can  infective  material  enter  the  healthy  intestine. 

(21)  Partial  or  complete  exclusion  may  be  resorted  to  as  a  prelimi- 
nary step  to  excision  in  cases  where,  at  the  first  operation,  removal  of 
the  diseased  bowel  gut  is  found  inadvisable  because  of  the  patient's 
condition. 

(22)  It  may  also  be  necessary  to  short-circuit  the  bowel  to  relieve 
obstruction  from  stricture  at  the  point  of  union. 

(23)  Exclusion  operations,  particularly  entero-anastomosis,  are 
less  dangerous  than  extirpation  because  they  require  less  time  and 
cause  little  or  slight  bleeding. 

(24)  Stricture  demands  practically  the  same  operative  treatment 
as  other  tubercular  intestinal  lesions;  consequently,  the  statistics  of 
operations  for  stenoses  have  been  gi\'en  with  procedures  employed  in 
the  treating  of  other  forms  of  bowel  tuberculosis,  but,  for  the  sake 
of  comparison,  a  summary  of  Xicoloysen's  statistics  has  been  appended. 

(25)  Strictures  occur  rarely  in  the  jejunum  and  duodenum,  but  are 
found  fairly  often  in  the  lower  ileum  and  cecal  regions,  and  are  usually 
single,  but  may  be  multiple. 

(26)  Broken-down  glands  easy  to  extirpate  should  be  removed,  but 
when  glands  are  simply  swollen  and  difficult  to  reach  they  are  best 
left  alone,  since  many  cures  have  followed  where  enlarged  nodes  were 
found  at  operation  that  were  not  removed. 

(27)  It  makes  very  little  difference  whether  one  removes  a  short 
or  long  piece  of  the  gut  in  so  far  as  the  severity  of  the  operation  is 
concerned,  for  on  many  occasions  either  a  few  inches  or  several  feet 
of  the  intestine  have  been  successfully  resected. 

(28)  The  suture-alone  method  is  preferable  to  the  Murphy  button 
or  other  mechanical  appliance,  reinforced  by  Lembert  stitches,  and 
side-to-side  should  take  precedence  over  end-to-side  or  end-to-end 
anastomosis  in  this  class  of  cases. 

(29)  The  frequency  with  which  enormous  tubercular  tumors  and 
single  or  multiple  strictures  have  been  encountered  indicate  that 
operative  measures  are  often  postponed  longer  than  they  should  be  in 
bowel  tuberculosis. 

•    (30)  Laparotomy  may  be  of  servdce  in  tubercular  peritonitis,  but 
is  useless  when  the  disease  involves  the  intestine. 


CHAPTER   XXV 

SYPHILITIC    ENTERITIS,    COLITIS,    AND    ENTEROCOLITIS 
TNTESTINAL    SYPHILIS,    DIARRHEA    IN 

GENERAL  REMARKS,   ETIOLOGY,  PATHOLOGY 

There  is  a  paucity  of  literature  relative  to  syphilitic  enterocolitis, 
but  a  study  of  it,  together  with  his  personal  experience,  has  convinced 
the  author  that  while  luetic  intestinal  lesions  sometimes  cause  chronic 
diarrhea,  they  do  so  less  often  than  older  writers  would  have  us  believe, 
and  this  is  surprising  when  one  takes  into  consideration  the  large 
number  of  people  who  suffer  from  syphilis  and  the  frequency  with 
which  the  disease  attacks  other  organs  or  parts  of  the.  body.  The 
statistics  of  two  decades  ago  indicate  that  intestinal  lues,  particularly 
of  the  rectum,  was  exceedingly  common,  and  no  doubt  many  cases  of 
chronic  diarrhea  were  attributed  to  this  disease. 

With  modern  diagnostic  methods  one  can  readily  ascertain  whether 
the  subject  is  syphilitic  or  not,  which  can  be  accomplished  by  dis- 
covering spirochetes,  obtaining  a  positive  Wassermann  reaction, 
and  administering  salvarsan.  which  eliminates  luetic  manifestations. 

Proctologists  and  others  who  frequently  study  the  lower  bowel 
through  a  proctosigmoidoscope  agree  that  syphilitic  lesions  here  are 
comparatively  rare,  and  that  strictures  common  to  the  rectum,  which 
formerly  were  attributed  to  lues,  are  caused  by  catarrhal  and  other 
forms  of  colitis  where  mixed  infection  plays  an  important  part. 

Old  text-books  devoted  to  diseases  of  the  rectum  attribute  from  40 
to  60  per  cent,  of  all  rectal  strictures  to  syphilis,  but  modern  works  on 
proctology'  do  not  assign  more  than  10  per  cent,  to  this  cause. 

In  the  past,  clinicians  and  investigators  often  mistook  the  lesions 
of  other  diseases  for  those  of  syphilis,  because  they  did  not  understand 
the  etiolog\'  of  lues,  were  not  familiar  with  proctoscopic  and  sigmoid- 
oscopic  examinations,  did  not  have  the  Wassermann  reaction  to  aid 
them,  and  were  not  accustomed  to  studying  the  feces  through  the 
microscope,  which  would  have  enaljled  them  to  find  entameba^.  dys- 
enteric bacilli,  Balantidium  coli,  helminths  (or  ova),  and  thus  differ- 
entiate between  the  different  types  of  infectious  colitis. 

Occasionally  the  author  has  obser\'ed  a  catarrhal  inflammation, 
erosions,  superficial,  then  deep  extensive  ulcers,  and.  finally,  stricture 
follow  each  other  in  moderate  or  quick  succession,  that  were  incident 
to  entamebic,  bacillary,  tuberculous,  or  gonorrheal  infection.  More 
often  he  has  encountered  catarrhal  coloproctitis,  which  when  neglected 
led  to  the  formation  of  the  above-enumerated  lesions  and  caused 
persistent  diarrhea,  a  condition  which  in  many  instances  had  been 
294 


GENERAL    REMARKS,    ETIOLOGY,    PATHOLOGY  295 

previously  diagnosed  as  syphilis  of  the  rectum.  The  author  does  not 
believe  that  lues  or  other  types  of  infectious  colitis  cause  extensive 
destruction  of  tissue,  but  that  they  break  the  coniinuiiy  of  the  mucosa, 
and  that  thereafter  mixed  infection,  participated  in  by  accidental  and 
obligate  pathogenic  micro-organisms,  takes  place,  as  a  result  of  which 
numerous  large  excoriated  ulcers  form  that  are  responsible  for  the 
persistent  diarrhea  and  stools  containing  pus,  blood,  and  mucus  which 
characterize  aggravated  cases  of  colitis. 

From  what  has  been  said  it  niciy  be  inferred  that  strictures  of  the 
lower  bowel  may  result  from  any  inflammatory  disease  of  the  colon 
accompanied  by  ulceration,  and  that  such  a  condition  is  seldom  brought 
about  by  luetic  involvement  of  the  intestine. 

The  author  has  treated  35  patients  suffering  from  diarrhea  who  gave 
a  history  of  s\'philis,  exhibited  stigmata  or  typic  luetic  manifestations, 
wherein  the  inflamed  ulcerative  or  stenotic  rectal  lesions  were  respon- 
sible for  the  trouble,  characteristic  and  diagnosed  as  luetic.  He  can 
recall  only  7  cases  of  chronic  diarrhea  which  were  attributed  to  syph- 
ilitic lesions  located  exclusively  in  the  small  intestine  or  colon.  Two  of 
these  patients,  one  six  (boy)  and  the  other  eighteen  (girl),  at  the  age  of 
one  month  had  congenital  syphilis  which  was  exhibited  by  Hutchin- 
son's teeth,  enlarged  fontanels,  mucous  patches  of  the  mouth  and 
throat,  and  fissures  abotit  the  anus  or  vulva.  In  each  case  one  or 
both  parents  admitted  having  syphilis,  and  the  diarrhea  and  other 
manifestations  improved  while  under  specific  treatment  and  relapsed 
when  it  was  discontinued,  as  was  shown  in  one  instance  by  a  positive 
Wassermann  reaction  obtained  later.  In  both  cases  the  rectum  and 
sigmoid  appeared  healthy,  and  because  of  this  and  the  fact  that  these 
little  patients  suffered  frequently  from  abdominal  cramps,  distention, 
and  soreness,  a  diagnosis  of  enteritis  was  made. 

Four  other  cases,  two  men  and  two  women,  whose  ages  ranged  from 
nineteen  to  thirty-seven,  suffered  from  acquired  syphilis;  each  ad- 
mitted having  had  a  chancre,  and  in  3  this  evidence  was  verified  by 
the  presence  of  typic  initial  cicatrices.  All  4  cases  gave  a  clear  his- 
tory of  having  suffered  from  the  usual  manifestations  of  lues — fever, 
skin  eruption,  erosions  of  the  mouth  and  throat,  enlarged  glands,  and 
falling  out  of  the  hair.  In  i  case,  a  man  twenty-three  years  of  age, 
the  clinical  diagnosis  of  lues  was  confirmed  by  finding  of  the  Spiro- 
chieta  pallida  and  obtaining  a  positive  Wassermann  reaction,  but  in 
the  other  3  cases  the  latter  methods  of  diagnosis  were  not  em[)lo\ed. 
since  the  patients  were  treated  before  their  discovery. 

The  diagnosis  of  syphilitic  diarrhea  in  these  cases  was  based  upon 
these -findings:  the  patients  had  syphilis,  the  fluid  movements  were 
controlled  by  antiluetic  treatment,  the  negati\-e  findings  of  the  fecal 
examinations,  and  no  other  infection  (dysentery,  tuberculosis,  etc.) 
which  would  account  for  the  diarrhea  could  be  discovered. 

The  seventh  case  was  a  bookmaker,  fifty  years  of  age,  riddled  with 
syphilis,  who  suffered  from  auto-intoxication  and  extensive  ulceration 
of  the  entire  colon  which  excited  a  most  persistent  diarrhea.     This 


296      SYPHILITIC    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

being  before  the  advent  of  appendicostomy  and  cecostomy,  colostomy 
was  advised,  and  when  the  author  attempted  to  Hft  the  bowel  upward 
it  tore  in  two,  and  it  was  with  great  difficulty  that  the  hard,  brittle, 
and  ragged  ends  were  brought  out  and  sutured  to  the  skin  to  form  the 
desired  anus.  The  entire  colon  was  involved,  and  many  deep  ulcers 
could  be  seen  through  the  intestinal  serosa.  After  a  painstaking 
examination  in  this  case  the  author  became  convinced  that  the  fre- 
quent and  fluid  movements  were  due  to  syphilitic  degeneration  of  the 
colon,  for  the  rectum  and  sigmoid,  as  high  as  they  could  be  inspected 
through  the  sigmoidoscope,  were  extensively  invohed  in  the  luetic 
process. 

In  obscure  cases  of  chronic  diarrhea,  where  syphilis  is  suspected, 
the  author  considers  macro-  and  microscopic  examination  of  the 
feces  exceedingly  important,  because  in  lues  the  findings  are  nega- 
tive, but  where  the  trouble  is  induced  by  dysentery,  tuberculosis, 
gonorrhea,  or  helminths,  the  stools  contain  the  specific  organisms  re- 
sponsible for  the  infection,  which,  when  found,  render  the  diagnosis 
positive. 

The  etiology  of  intestinal  syphilis  inducing  diarrhea  is  the  same 
(viz.,  spirochetes)  as  that  for  lues  affecting  other  parts  of  the  body. 
This  dreaded  disease  may  be  contracted  through  heredity  from  either 
or  both  parents,  or  by  direct  infection  during  sexual  intercourse.  Phys- 
icians have  been  known  to  become  inoculated  with  syphilitic  virus 
while  operating  upon  or  treating  syphilitic  subjects,  and  others  have 
been  infected  through  vaccination,  nursing,  kissing,  drinking  from 
unclean  vessels,  or  by  using  a  syringe,  rectal  tube,  or  toilet  articles 
which  had  been  previously  employed  by  an  individual  suffering  from 
lues. 

Syphilis  originally  manifests  itself  in  the  form  of  a  chancre  upon 
the  penis,  labia,  lip,  tongue,  skin,  rectum,  or  at  the  anus.  Persons 
suffering  from  acquired  syphilitic  diarrhea  show  or  give  a  history 
of  having  had  the  initial,  secondary,  and  tertiary  stages  of  the  dis- 
ease, while  children  with  congenital  syphilis  may  be  affected  "with 
gummata  and  late  lesions  of  lues  without  having  had  the  symptoms 
common  to  the  earlier  stages  of  acquired  syphilis. 

The  theory  of  Lustgarten  that  lues  is  caused  by  a  micro-organism 
resembling  tubercle  and  smegma  bacilli  has  been  rejected  in  favor  of 
that  of  Schaudinn  and  Hoffmann,  who  since  1905  have  maintained 
that  the  SpirochcBta  pallida  (Treponema  pallidum)  are  the  etiologic  fac- 
tors in  syphilis.  Spirochetes  have  been  so  frequently  demonstrated 
in  the  initial  sore,  lesions  of  the  skin,  mucosa,  and  involved  lymphatics 
by  laboratory  workers  at  home  and  abroad  that  one  feels  compelled 
to  admit  that  it  is  the  chief  or  sole  cause  of  syphilis. 

It  is  unnecessary  here  to  give  a  detailed  description  of  Spirochaeta 
pallida,  since  standard  works  on  sy philology  and  pathologv'  give  the 
necessary  information  concerning  it,  and,  further,  because  its  presence 
cannot  be  demonstrated  in  the  later  stages  of  lues,  and  more  especi- 
ally in  persons  who  have  taken  antisyphilitic  treatment.     Spirochetes 


PATHOLOC.Y  297 

have  been  demonstrated  in  considerable  numbers  in  the  intestinal 
mucosa  of  a  luetic  fetus  (Simmonds),  and  observed  in  strand-like  for- 
mation about  the  glands  in  an  infant  who  died  at  the  age  of  four  days 
from  purulent  peritonitis  (Frankel).  When  discoverable,  they  are 
l)resent  in  considerai)le  numbers  on  and  in  the  ulcerated  areas,  in  the 
mucosa  and  glands  of  Lieberkiihn,  or  the  part  of  the  gut  abundantly 
supplied  with  lymphatics.  As  a  rule,  they  are  not  demonstrable  in 
the  lesions  or  discharges  of  patients  suffering  from  syphilitic  colitis 
causing  chronic  diarrhea. 

Pathology. — Chronic  diarrhea  may  be  induced  l)y  syphilis  involving 
the  small  intestine,  colon,  or  rectum,  individually  or  collectively. 
Congenital  and  acquired  luetic  lesions  which  cause  diarrhea  are  en- 
countered very  much  more  frequently  in  the  rectum  than  in  either  the 
small  intestine,  colon,  or  sigmoid  flexure.  It  is  an  interesting  and  es- 
tablished fact  that  when  syphilis  attacks  the  bowel  above  the  rectum 
it  shows  a  predilection  for  and  involves  the  jejunum  more  frequently 
than  the  stomach,  duodenum,  ileum,  or  colon. 

No  one  has  offered  a  satisfactory  explanation  as  to  why  lues  attacks 
the  jejunum  and  rectum  so  much  more  frequently  than  other  parts  of 
the  bowel,  nor  do  we  know  why  a  purely  syphilitic  stricture  of  the 
rectum  should  be  met  with  so  much  more  often  (seven  to  one)  in  women 
than  in  men.  There  must  be  some  reason  why  this  is  so,  because  other 
ulcerative  lesions  of  the  parts  of  the  bowel  do  not  show  the  same 
tendency  to  involve  these  particular  segments  of  the  gut  so  freciucntly, 
and  attack  women  and  men  in  about  the  same  ratio. 

The  rectum  and  anus  are  usually  involved  in  both  hereditary  and 
acquired  intestinal  syphilis,  but  when  the  small  intestine,  especially 
the  jejunum,  is  affected,  lues  is  usually  congenital,  and  a  careful  ex- 
amination will  reveal  that  the  patient  has  Hutchinson's  teeth,  anal 
fissures,  enlarge  fontanels,  or  other  stigmata  of  inherited  syphilis. 

The  luetic  lesions  which  cause  diarrhea  vary  greatly  as  regards 
their  location  and  appearance,  and  pathologic  changes  may  involve 
the  superficial  mucosa,  extend  completely  through  the  gut  and  attack 
the  mesentery,  or  cause  perforation  and  peritonitis. 

More  is  known  of  the  clinical  aspect  and  the  gross  and  minute 
I)athology  of  the  luetic  rectum  than  of  the  symptoms  and  the  ana- 
tomic changes  which  take  place  in  syphilis  of  the  small  intestine  and 
colon  because  syphilis  is  more  common  in  this  region,  and  the  disease 
has  been  more  closely  studied  here,  owing  to  the  fact  that  the  rectum 
is  accessible  to  digital  and  proctoscopic  examination,  removal  of  dis- 
eased tissue  for  microscopic  examination  is  easily  accomplished,  and, 
moreover,  the  feces  and  discharges  are  readily  obtained  for  inspection 
and  analysis.  In  acquired,  the  destruction  of  tissue  is  greater  than  in 
congenital  intestinal  syphilis  because  the  disease  has  existed  longer  and 
progressed  farther.  Adults  and  children  who  have  inherited  syphilis 
and  suffer  from  chronic  diarrhea  show  about  the  same  intestinal  lesions 
as  those  who  suffer  from  acquired  lues,  though,  as  a  rule,  they  are  not 
so   extensive,   and    there    is   no   appreciable    difference    between    the 


298       SVPHII.ITIC    ENTKRITIS,    COLITIS,    ENTKROCOLITIS,    DIARRHEA    I\ 

changes  which  take  place  in  the  tissues  in  the  two  forms  in  the  pres- 
ence of  syphiUtic  cohtis. 

There  is  a  difference  of  opinion  as  to  whether  the  lymph  or  blood  is 
the  carrier  of  the  infection  to  the  intestine,  but  from  our  present 
knowledge  it  would  appear  that  the  blood  is  mainl\-  responsible, 
though  there  is  considerable  evidence  to  support  the  claim  that  both 
lymph  and  blood  pla>'  their  respective  parts  in  producing  intestinal 
syphilis.  Once  the  bowel  is  involved,  the  blood-vessels  become  the 
chief  factors  in  furthering  the  disease  because  the  lumen  of  the  arteries 
is  gradually  diminished  b\'  progressi\'e  endarteritis  and  connecti\-e- 
tissue  thickening  of  the  adventitia,  and,  in  consequence,  the  tissues 
are  deprived  of  blood,  necrosis  takes  place,  and  ulcers  form,  which, 
when  healed,  sometimes  cause  strictures. 

Chronic  diarrhea  of  syphilitic  origin  may  be  induced  by  a  variety 
of  intestinal  lesions:  (a)  catarrhal  inflammation  (enteritis  and  colitis 
syphilitica);  (b)  ulcers;  (c)  gummata;  and  (d)  strictures.  The  degree 
of  the  diarrhea  varies  in  different  cases  depending  upon  the  duration 

of  the  disease  causing  it,  the  part  played  by 
mixed  infection,  and  extent  and  character 
of  the  lesion. 

Enteritis  and  Colitis  Syphilitica. — Ca- 
tarrhal inflammation  of  the  small  intestine 
and  colon  incident  to  s>philis  is  encoun- 
tered more  frequently  in  the  earlier  than 
the  later  stages  of  intestinal  lues,  but  the 
manner  in  which  the  inflammatory  condi- 
1  tion  is  prodticed  is  not  known  unless,  as 
JuUien  belie\'es,  the  infection  takes  place 
through  the  lymphatics,  though  some  one 
has  suggested  it  is  due  to  toxins  emanating 

•  ^\  43 .-Syphilitic  ulcera-     jYom    the   Spiroch^ta  pallida  which  have, 
tion  01  the  anal  canal  and  rec-         111  1 

turn  (after  author's  case).  through    the  excretory   process,    been    de- 

posited upon  the  mucosa. 

Syphilitic  Ulcers  of  the  Intestine. — Intestinal  ulcers  (Fig.  43)  of 
syphilitic  origin  which  incite  chronic  diarrhea  may  be  single  or  mul- 
tiple, in  pairs  or  groups,  closely  assembled  or  widely  scattered  through- 
out the  bowel,  superficial  or  deep,  variable  in  color,  and  their  edges  may 
be  ragged,  sharply  defined,  or  rounded.  In  enteritis  syphilitica  there 
is  nothing  more  than  slight  erosions  of  the  mucosa,  but  when  the  lu- 
etic process  attacks  the  follicles  of  Lieberktihn  or  Peyer's  patches  the 
ulcers  are  larger  and  deeper.  The  most  destructi\e  syphilitic  ulcers 
are  those  formed  by  the  breaking  down  of  lesions,  which  vary  in  size, 
are  crater-like  in  character,  and  cause  the  most  persistent  type  of 
luetic  colitis. 

In  contradistinction  to  other  ulcerative  intestinal  lesions,  luetic 
ulcers  usually  have  a  rounded,  raised,  hard  border  instead  of  under- 
mined edges.  Syphilitic-like  ttibercular  ulcers  are  inclined  to  follow 
the  blood-vessels  and  encircle  the  bowel,  and  as  healing  takes  place 


PATHOIXXiY    OF    GUMMATA    AND    STRICTURI<;S  299 

and  cicatricieil  tissue  accumulates,  the  scars  are  prone  to  contract  and 
form  sfrictiircs.  Multiple  stenoses  complicate  syphilis  more  frequently 
than  other  intectious  diseases  of  (he  intestine,  of  which  diarrhea  is  a 
manifestation. 

Syphilitic  ulct'ralion,  in  llic  form  of  (hancrcs,  nuicous  patclies, 
and  gummata,  attack  the  rectum  in  different  stas^^es  (jf  lues,  but  ulcers 
of  the  small  intestine  and  colon  occur  early  in  the  secondary  and  ter- 
tiary stages  of  tlu'  disease.  Mixed  infection  is  more  active  when  the 
lesions  are  in  the  colon  and  rectum,  and  ttiarrhea  is  more  j^ersistent 
than  when  they  are  located  in  the  small  intestine.  In  either  case, 
when  ulcers  are  numerous  or  extensive  and  deep,  the  evacuations  are 
more  fre{[uent,  and  contain  a  greater  amount  of  pus,  blood,  and  mucus 
than  when  the  ulcerative  process  is  insignificant.  In  some  instances, 
in  congenital  and  acquired  syphilis  involving  the  upper  segments  of 
the  bowel,  from  twenty  to  fifty  ulcers  have  been  observed.  Usually 
syphilitic  diarrhea  results  most  frequently  from  involvement  of  the 
rectum,  and  the  ulcers  causing  the  loose  movements  under  such  cir- 
cumstances will  be  described  under  a  separate  heading. 

Pathology  of  Gummata  and  Strictures. — (Gummatous  infiltration 
is  generalh  conceded  to  be  the  ukjsI  ccjmmon  manifestation  of  intes- 
tinal syphilis  attacking  the  small  intestine  and  colon.  In  the  rectum, 
however,  gummata  are  exceedingly  rare,  and  a  perusal  of  the  literature 
and  the  standard  works  on  proctology  show  that  but  few  authenticated 
cases  of  gummatous  infiltration  of  this  part  of  the  intestine  have  been 
reported.  In  a  large  experience  covering  twenty  years  the  author 
has  encountered  this  condition  but  three  times. 

("lummata  involving  the  small  intestine  and  colon  may  be  single  or 
multiple  and  appear  as  diminutive  miliary  ovoid  swellings,  large  saucer- 
shaped  elevations,  or,  more  frequently,  as  raised  or  ridge-like  infiltra- 
tions which  encircle  the  gut  at  a  right  angle,  usually  following  the  direc- 
tion of  the  blood-vessels.  There  has  been  considerable  discussion  by 
writers  upon  syphilology,  and  experiments  have  been  made  to  deter- 
mine in  just  what  layer  of  the  gut  wall  gummata  originate.  All 
authorities  agree,  however,  that  in  certain  cases  during  its  progress  the 
infiltration  ma\'  include  singly  or  collecti\'ely  the  mucosa,  submucosa, 
muscularis,  and  serosa,  or  extend  to  and  involve  the  mesentery. 
Almost  conclusive  evidence  is  at  hand  to  support  the  theory  that 
this  type  of  intestinal  syphilis  originates  in  the  connective  tissue 
of  the  submucosa,  and  ma\-,  wlien  untreated,  extend  in  either  or 
both  directions,  according  to  tiie  duration  of  tlu'  disease  and  its 
\irulence. 

Ciimimata  may  remain  intact  or  produce  diarrhea  ihrougli  obstruc- 
tion where  they  encircle  the  bowel  or  project  into  its  lumen.  These 
infiltrating  tumors  may  also  imdergo  retrogressix  i'  changes  wlu-re  one 
or  many  sujierficial  or  penetrating  ulcers  expose  the  terminal  nerve- 
lilaments  to  the  intestinal  contents  which  ser\'e  to  irriiatt'  the  nervous 
mechanism,  and  through  reflex  action  excite  frecjuent  and  prolonged 
peristaltic  contraction  and  an  increase  in  the  number  of  the  evacuations. 


300      SYPHILITIC    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

These  ulcers  may  amount  to  nothing  more  than  superficial  erosions  of 
the  mucous  membrane,  or  they  may  be  progressive,  and  in  successive 
stages  involve  one  or  all  of  the  intestinal  tunics  and  cause  perforation 
during  fetal  life  or  subsequently,  a  complication  that  has  been  observed 
a  number  of  times.  The  author  has  treated  but  one  patient,  and  in 
this  instance  death  took  place  from  peritonitis  within  forty-eight  hours. 
Unfortunately,  he  was  unable  to  secure  a  postmortem  to  determine 
whether  or  not  the  perforation  was  caused  by  a  degenerating  gumma 
or  syphilitic  colitis.  The  patient  was  a  woman  forty  years  of  age,  who 
had  all  the  manifestations  of  lues,  but  no  cachexia  or  other  symptoms 
which  would  lead  one  to  suspect  cancer,  tuberculosis,  or  dysentery. 
A  diagnosis  of  gummatous  infiltration  was  based  upon  the  clinical 
history,  conspicuous  evidence  of  syphilis,  and  the  peculiar  saucer- 
shaped  swelling  located  in  the  central  part  of  the  ascending  colon 
which  caused  partial  obstruction.  These  negative  symptoms,  together 
with  the  fact  that  the  abdomen  became  rapidly  distended  and  peri- 
tonitis followed  shortly  the  feeling  of  sharp  pain  at  the  site  of  the 
tumor,  led  the  author  to  believe  that  perforation  had  taken  place 
incident  to  a  penetrating  ulcer  and  not  as  the  result  of  obstruction. 
This  patient  had  been  placed  in  the  hospital  and  was  being  prepared 
for  intestinal  resection,  but  perforation  occurred  and  she  died  before 
the  operation.  Non-degenerating  and  ulcerating  gummatous  infiltra- 
tions invariably  lead  to  peritoneal  involvement  and  the  formation  of 
false  membranes  or  adhesions  which  surround  or  bind  the  bowel  to 
other  organs,  or  cause  the  massing  together  of  several  loops  of  intes- 
tine by  exudates.  When,  as  a  result  of  the  destructive  process,  infec- 
tion or  perforation  takes  place,  peritonitis  ensues  or  abscess  and  a 
fecal  fistula  form.  In  deplorable  cases  the  mesentery,  through  exten- 
sion of  the  inflammation  and  infiltration,  becomes  swollen,  hard,  and 
tends  to  produce  contraction,  narrowing,  or  angulation  of  the  gut. 

There  is  very  little  if  any  difference  between  the  character  of 
gastric  and  intestinal  gummata.  In  both,  the  mucosa,  submucosa, 
and  muscularis  may  be  involved  by  the  infiltrating  process,  which  is 
of  the  round-celled  variety.  Brunner,  Kleinschmidt,  and  other  close 
students  of  intestinal  syphilis  have  recently  confirmed  the  views  of 
Mracek,  who  maintains  that  the  infiltration  begins  in  the  adventitia 
of  the  arterial  walls  and  gradually  progresses  until  it  greatly  narrows 
or  completely  occludes  the  lumen  of  the  vessels,  and  that  the  veins  do 
not  become  involved  until  later.  Frequently,  the  narrowing  or 
obliterating  process  which  occurs  in  the  arterioles  as  the  adventitia 
becomes  involved  is  accelerated  by  changes  which  take  place  simul- 
taneously in  the  intima  as  a  result  of  an  obliterating  endarteritis.  If 
the  blood-vessels  become  partially  or  completely  incapacitated  in  this 
manner,  it  makes  plain  the  reason  why  ulceration  is  a  common  mani- 
festation of  gummatous  tumors,  for  impairment  to  the  circulation 
necessarily  brings  about  fatty  degeneration  and  necrosis  of  the  involved 
structures.  As  the  necrotic  tissue  gives  way,  small  or  large,  superficial 
or  deep  ulcers  form  and  add  to  the  gravity  of  the  situation.     Ulcera- 


PATHOLOGY    OF    GUMMATA    AND    STRICTURES  30I 

tion  usually  begins  in  the  center  of  the  tumor  mass,  and  individual 
ulcers  have  a  greenish-colored  base  and  a  raised  sclerotic  border. 
When  retrogressive  changes  have  progressed  to  a  considerable  extent 
a  number  of  ulcerated  areas,  \ariable  in  size,  shape,  and  depth,  are  to 
be  seen. 

Under  such  circumstances  the  surface  of  the  gumma  presents  cer- 
tain peculiar  characteristics,  for  at  one  point  a  rapidly  extending  ulcer 
may  be  observed,  at  another  one  marked  by  healthy  granulations  and 
parth-  healed,  and  at  still  another  a  depression  covered  with  a  glisten- 
ing white  scar,  which  indicates  the  location  of  a  healed  or  completely 
cicatrized  ulcer.  If  the  destructive  process  is  not  now  arrested,  the 
ulcerated  areas  rapidly  extend,  become  deeper,  encircle  the  bowel, 
and  when  healed  cause  partial  or  complete  intestinal  occlusion  (stric- 
ture). In  some  instances  the  blocking  is  partialK-  attributable  to 
inrtammatory  exudates  deposited  in  the  gut  wall.  In  s\-philitic  as 
in  other  connective-tissue  strictures  involving  the  intestinal  tunics, 
the  peritoneum  is  thickened  and  the  bowel  is  usually  bound  to  the 
adjacent  structures  by  adhesions  or  exudates. 

Kleinschmidt  observed  this  connective-tissue  invoh'ement  of  the 
serosa  and  interspersed  nodular  villus  formations,  and  upon  cross-sec- 
tion found  thelymph-\-essels  packed  with  round  cells,  the  muscular  coats 
disturbed,  and  the  muscle  bundles  torn  apart  by  invading  connective 
tissue,  but  he  did  not  find  the  diffuse  infiltration  of  the  mucosa  de- 
scribed by  others.  According  to  his  interpretation,  the  plate-shaped 
thickenings  noticeable  in  gummata  are  due  to  a  hypertrophy  of  the 
submucosa  following  an  infiltration  which  originates  in  the  arterial 
adventitia. 

Syphilitic  strictures  invoking  the  small  bowel  or  colon  ma>' 
result  from  congenital  or  acquired  lues,  and  are  encountered  very 
much  less  frequently  than  stenoses  of  the  rectum  (Fig.  44).  In  this 
class  of  cases  the  patient  suffers  from  an  obstructive  diarrhea,  and  the 
number  and  consistence  of  the  stools  depends  upon  the  number  of 
constrictions,  the  degree  of  obstruction  caused  by  them,  and  upon 
the  extent  of  the  complicating  ulceration.  Obstructive  diarrhea  of 
syphilitic  origin  may  be  caused  by  a  gumma  which  projects  into  the 
bowel,  resulting  in  a  narrow  circular  constriction  (a  cicatricial  ring),  or 
b>'  a  tube-like  narrowing  of  the  gut  induced  by  a  prolonged  subacute 
infiammation  which  results  in  fibrosis  and  thickening  of  all  the  intes- 
tinal coats,  showing  a  tendency  to  contract  and  form  the  so-called 
i!,as-pipe  intestine  (tubular  stricture).  Strictures  in  all  parts  of  the 
intestine  are  invariably  complicated  by  ulceration  at  and  above  the 
constriction,  and  when  the  ulcers  are  superficial  the  evacuations 
contain  a  small  amount  of  admixed  pus,  blood,  and  mucus,  but  when 
they  are  extensive  and  deep  the  discharge  is  copious  and  the  move- 
ments are  fluid  and  frequent.  Sometimes,  when  the  lesions  are 
penetrating  or  crater-like,  the  discharge  of  fecal  or  other  infectious 
matter  becomes  pocketed  in  them,  infection  takes  place,  and  termi- 
nates in  abscess  or  fistula,   or   perforation   occurs  and   the   patient 


302       SYPHILITIC    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

suffers  from  a  localized  or  general  peritonitis,  possibly  pyostercoral 
abscess  and  adhesions,  and  one  or  all  conditions  may  interfere  with 
the  functionating  power  of  the  intestine. 

Pathology  of  Anorectal  Syphilis. — All  of  the  luetic  lesions 
{proctitis,  syphilitica,  secondary  and  tertiary  ulceration,  gummata,  and 
strictures)  found  in  the  small  and  large  intestines  are  encountered  in 
the  rectum,  but  more  frequently  and  in  an  aggravated  form.  In  ad- 
dition, one  sometimes  has  to  deal  with  chancres,  luetic  condylomata 
(Fig.  45)  of  the  perianal  skin,  and  the  fissures  of  congenital  syphilis. 
Owing  to  trauma  of  the  inflamed  and  ulcerated  mucosa,  lodgment  of 
feces  under  the  edges  of  undermined  ulcers  during  defecation,  mixed 


Fig.    44.- 


-Multiple   syphilitic    stricture:   A,  In  rectal   ampulla;   B,  in   sigmoid   flexure 
(after  author's  case). 


infection,  and  retention  in  the  lower  bowel  of  foul  discharges,  intestinal 
syphilis  is  met  in  its  worst  form  in  the  rectum,  and  complications  that 
do  not  occur  above  are  often  encountered  here — viz.,  numerous  poly- 
poid-like excrescences,  abscess,  fistula,  hypertrophied  papillce,  skin  tags, 
fissures,  erosions  of  the  skin,  and  wart-like  growths,  which  involve  the 
mucosa,  integument,  or  both,  and  the  anal  canal  and  skin  of  the  but- 
tocks are  constantly  bathed  by  an  acrid  discharge  having  a  disgusting 
odor. 

Condylomata  occur  in  patches,  have  a  stem-like  attachment,  and 
club-like  distal  extremities.     These  growths  are  highly  infectious,  and 


PATHOLOGY    OF    GUMMATA    AND    STRICTURES 


303 


new  collections  of  warts  appear  upon  parts  of  the  opposite  healthv  but- 
tocks when  cond\iomata  are  not  isolated.     The  author  treated  a  man 


Figs.  45.  40.^InUHlious  1  syphilitic j  condylomata  ^condylomata  lata;  invohnng  the 
anus  (above):  penis  and  interdigital  spaces  (below).  Complications  of  a  luetic  colitis 
(after  author's  case). 

who  infected  his  toes  and  penis  by  scratching  after  having  treated  his 
anal  condylomata  (Figs.  45,  46).  These  excrescences  are  caused  by 
the  syphilitic  discharge  from  the  rectum. 


CHAPTER   XXVI 

SYPHILITIC    ENTERITIS,    COLITIS,    AND    ENTEROCOLITIS 
(INTESTINAL    SYPHILIS  ,    DIARRHEA    IN    .  Continued) 

SYMPTOMS,  DIAGNOSIS,   PROGNOSIS 

Symptoms. — The  gastro-intestinal  symptoms  of  syphilitic  do  not 
differ  materially  from  those  of  catarrhal,  eutamebic,  bacillary,  and  other 
forms  of  colitis  accompanied  by  inflammatory^  and  ulcerative  changes 
in  the  mucosa  or  strictures  in  the  small  or  large  intestine.  Syphilitic 
colitis  can  usually  be  distinguished  from  other  infectious  diseases  of 
the  bowel  by  the  constitutional  manifestations  of  the  affection — mucous 
patches  in  the  mouth,  throat,  and  about  the  anus,  falling  out  of  the 
hair,  skin  eruption,  and  getting  a  history-  of  the  patient's  having  had  a 
chancre. 

Sufferers  from  congenital  syphilis  usually  exhibit  stigmata,  viz., 
Hutchinson's  teeth,  enlarged  fontanels,  etc.,  which,  in  connection 
with  the  above  symptoms,  indicate  that  the  gastro-intestinal  dis- 
turbances— diarrhea,  cramps,  pus,  blood,  and  mucus  in  the  stools — are 
induced  by  syphilitic  involvement  of  the  intestine.  Persistent  diarrhea 
incident  to  lues  is  occasionally  secondan.-  to  enteritis  syphilitica,  but 
in  the  vast  majority  of  cases  is  caused  by  inflammatory  or  ulcerative 
lesions  of  the  colon,  sigmoid  flexure,  and  rectum,  and  the  frequency  of 
the  stools  and  amount  of  the  contained  discharge  is  ver\^  much  greater 
when  the  lesions  are  situated  low  down  than  when  high  up  in  the  bowel. 

Intestinal  syphilis  when  congenital  may  excite  a  diarrhea  which 
manifests  itself  at  birth  or  later,  and  the  frequent  and  fluid  move- 
ments may  continue  indefinitely  until  the  child  dies  from  exhaustion 
or  recovers  as  the  result  of  intelligent  antisyphilitic  treatment. 

In  so  far  as  the  author  has  been  able  to  observe,  the  character  of  the 
stools  in  syphilitic  subjects  suffering  from  diarrhea  var\-.  dependent 
upon  whether  or  not  the  lues  involves  the  small  intestine  alone  or  in 
conjunction  with  the  stomach,  or  is  complicated  by  digestive  dis- 
turbances or  other  infectious  diseases  of  the  intestine,  such  as  tuber- 
culosis and  dysentery-.  Usually  children  who  suffer  from  luetic 
diarrhea  show  the  more  common  manifestations  and  stigmata  of  con- 
genital syphilis,  such  as  Hutchinson's  teeth,  ocular  disturbances,  ca- 
chexia, snufiles,  melena,  erosions  of  the  mouth,  nose,  or  throat,  pem- 
phigus syphilitica,  fissures  or  extensive  ulcerated  areas  in  the  anal 
canal,  at  the  anus  or  vaginal  outlet,  together  with  enlargement  of 
liver,  spleen,  and  lymphatic  glands.  The  stools  are  fluid,  contain  a 
variable  amount  of  mucus  slightly  stained  with  blood,  and  induce 
tenesmus  when  evacuated.  The  movements  are  offensive  and  irri- 
304 


SYMPTOMS  305 

tating,  and  cause  considerable  burning  pain  during  and  following 
defecation  through  their  irritati\-e  effect  up(jn  the  raw  surfaces  of  the 
anorectal  region.  When  there  are  gastric  disturbances  the  evacua- 
tions become  exceedingly  frequent  and  contain  considerable  quantities 
of  pus,  lilood,  or  mucus  and  remnants  of  undigested  milk  and  other  food. 
Infants  and  children  afflicted  with  congenital  syphilis,  except  when 
carefully  handled,  suffer  greatly  from  excoriations  of  the  mouth,  raw 
genitals,  and  erosions  of  skin  about  the  anus,  owing  to  the  irritation 
caused  by  the  acrid  discharge  which  so  frequently  bathes  them. 
Pain  from  this  source  is  much  less  in  children  who  undergo  specific 
treatment,  and  have  the  excoriated  parts  frequently  bathed  and  dusted 
with  talcum  and  calomel  (equal  parts),  or  smeared  over  with  an  oint- 
ment containing  calomel  or  mercury  in  some  form,  in  combination 
with  orthoform,  analgin,  or  eucain. 

Colic  is  a  common  manifestation  of  intestinal  syphilis  in  adults 
and  children,  but  the  latter  suffer  from  it  more  frequently  and  severely 
than  the  former.  When  the  stomach  is  involved  in  the  syphilitic 
process  the  patient  has  more  or  less  nausea  and  vomiting,  but  compara- 
tively little  gastric  pain.  Nearly  all  infants  and  children  who  suffer 
from  intestinal  or  gastro-intestinal  lues  are  weaklings.  Some  rapidly 
improve  when  they  are  properly  fed  and  put  on  specific  treatment. 
Others  continue  to  decline  in  spite  of  all  therapeutic  measures. 

Syphilis  of  the  small  intestine  and  colon  is  encountered  more  rarely 
in  adults  than  in  children,  and  but  few  cases  of  chronic  diarrhea  from 
this  source  ha\'e  been  reported.  Consequently,  but  little  is  known  of 
the  symptom-complex  of  intestinal  lues  causing  loose  movements. 

Except  for  the  ordinary'  indications  of  syphilis,  there  is  very  little 
difference  between  the  manifestations  of  intestinal  lues  and  those 
induced  by  entameba\  tubercular  and  other  bowel  affections,  accom- 
panied by  inflammation,  ulceration,  or  stricture  of  the  colon,  sigmoid 
flexure,  and  rectum. 

When  diarrhea  is  due  to  uncomplicated  enteritis  syphilitica  the 
patient  may  have  from  two  to  four  stools  daily,  which  contain  con- 
siderable mucus,  possibly  a  tinge  of  blood,  but  no  pus.  \\'here  there 
is  both  inflammation  and  ulceration  of  the  mucosa,  the  daily  stools 
increase  proportionately  with  the  number  and  extent  of  the  ulcerated 
areas.  When  the  destruction  of  tissue  is  moderate  the  patient  may 
not  have  more  than  fi\e  or  six  movements  daily,  but  in  very  bad  cases 
he  may  have  anywhere  from  eight  to  twenty  fluid  mo\ements  which 
contain  a  considerable  amount  of  mucus,  pus,  and  blood. 

In  cases  where  the  disease  has  been  allowed  to  go  untreated,  and 
one  or  more  strictures  have  formed  in  the  small  intestine  or  colon,  the 
patient  suffers  from  obstruction  in  addition  to  the  diarrheal  manifes- 
tations mentioned  above.  In  the  beginning  of  stricture  constipation  is 
present  to  a  greater  or  less  degree,  then  there  is  constipation  alternating 
with  diarrhea,  and  still  later,  when  the  bow^el  becomes  almost  occluded, 
diarrhea  predominates  because  nothing  but  fluid  stools  can  get  by 
the  constriction. 


306      SYPHILITIC    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

The  author  has  known  patients  who  suffered  from  stenosis  of  the 
small  bowel  to  pass  perfectly  formed  solid  movements,  but  the  feces 
escaped  through  the  stricture  and  passed  into  the  large  bowel,  where 
they  remained  until  they  became  solidified.  Such  instances  are  of 
rare  occurrence  because  in  this  class  of  cases  the  nervous  mechanism 
controlling  the  gastro-intestinal  tract  is  disturbed,  and  this  leads  to 
frequent  and  prolonged  peristaltic  contractions,  which,  in  turn, 
hurr\'  the  feces  through  the  lower  bowel  as  soon  as  they  pass  the 
obstruction. 

Flatus,  to  a  greater  or  less  extent,  complicates  syphilitic  diarrhea 
induced  by  luetic  enteritis  and  ulceration  of  the  small  intestine  or 
colon,  but  when  the  patient  suffers  frequently  and  greatly  from  gas 
distention  and  meteorism.  the  gut  is  usually  strictured.  A  constricted 
bowel  is  ven,'  erratic,  and  at  times,  when  in  a  quiescent  state,  flatus  and 
feces  may  pass  the  block  freely  and  cause  but  little  discomfort,  but 
when  it  is  irritated  through  the  presence  of  gas,  a  fecolith,  or  acrid 
discharge,  enterospasm  sometimes  inter^-enes,  and  there  is  a  simul- 
taneous contraction  of  the  circular  and  longitudinal  muscle-fibers  of  the 
intestine  in  the  neighborhood  of  the  stricture,  which  causes  cramps  in 
addition  to  the  discomfort  consequent  upon  the  gas  and  feces  retained 
above  the  contracted  segment  of  intestine.  When  enterospasm  lasts 
for  several  hours  or  longer  the  patients  also  suffer  from  nausea,  vomit- 
ing, and  the  usual  manifestations  of  intestinal  obstruction  and  auto- 
intoxication. 

In  marked  cases  of  stricture  sometimes  it  is  easy  to  feel  and  see  the 
strong  peristaltic  contractions  of  the  intestine  through  the  parietes 
when  peristalsis  is  stimulated  by  the  application  of  electricity  or  by  a 
sudden  and  hard  tap  of  the  finger  made  upon  the  abdomen  near  the 
stricture. 

Lues  frequently  involves  the  liver,  spleen,  lymphatic  glands,  mus- 
cles (sternocleidomastoid),  bone,  testes,  and  the  ners-es  or  their  centers, 
causing  tabes,  paresis,  trophic  disturbances,  etc.  Knowing  this, 
in  studying  chronic  diarrhea  supposedly  of  luetic  origin  it  is  well  to 
examine  the  organs  and  regions  named,  and  to  be  on  the  lookout  for 
manifestations  elsewhere  that  might  be  caused  by  syphilitic  invasion  in 
parts  other  than  the  intestine,  which,  when  found,  are  of  great  assist- 
ance in  clearing  up  the  diagnosis. 

The  author  believes  that  in  the  adult,  when  the  syphilitic  proc- 
ess attacks  the  intestine  sufficiently  to  produce  chronic  diarrhea, 
evidences  of  luetic  involvement  in  other  parts  of  the  body  can  be 
found  when  diligently  sought  for.  In  a  case  he  saw  with  another 
physician,  that  of  a  negro  woman  thirty-two  years  of  age,  there  was  a 
deep,  clear-cut  or  punched-out  gummatous  ulcer  in  the  center  of  the 
forehead  and  also  numerous  and  extensive  luetic  ulcers,  phagedenic  in 
character,  about  the  anus  and  vulva. 

The  early  manifestations  of  syphilis  are  seldom  demonstrable  in 
persons  suffering  from  intestinal  syphilis,  but  mucous  patches  of  the 
mouth,  throat,  and  anus,  ocular  disturbances,  ulcerating  bone  lesions. 


DIAGNOSIS  307 

and  syphilids  have  been  frec|uenll\'  observed  in  connection  with 
chronic  hictic  diarrhea. 

As  a  rule,  individuals  who  suffer  from  syphilitic  diarrhea  are  not 
del)ilitated,  suffer  less  severely  from  frequent  fluid  movements,  cramps, 
gas  distention,  and  intestinal  intoxication  than  persons  afflicted  with 
the  other  types  of  enterocolitis. 

Luetic  lesions — catarrh,  ulceration,  or  stricture  located  in  the 
lower  sigmoid  flexure  and  rectum — invariably  cause  more  distress  than 
when  located  in  the  colon  or  small  intestine  l)ecause  they  incite  an 
almost  incessant  desire  to  stool,  bearing-do%vn  sensations,  weight  and 
fulness  in  the  bowel,  burning  pain  in  the  rectum,  frequently  complicated 
by  abscess,  fistula,  and  excoriation  of  the  perianal  skin,  and  incite  a 
more  aggravated  type  of  diarrhea. 

Diagnosis. — In  some  instances  it  is  comparatively  easy  to  diagnose 
chronic  diarrhea  induced  by  luetic  lesions  of  the  bowel,  but  in  others 
it  is  extremely  difficult  or  impossible  to  differentiate  syphilitic  from 
other  types  of  colitis  causing  chronic  diarrhea.  With  a  negative 
history  as  regards  chancre,  absence  of  congenital  stigmata,  and  the 
characteristic  manifestations  of  acquired  syphilis,  and  there  remains 
a  doubt  as  to  whether  or  not  the  frequent  stools  are  incited  by  syphilitic 
or  other  lesions,  the  patient  should  be  temporarily  placed  upon  an 
antispecific  treatment.  If  under  such  circumstances  he  rapidly  ini- 
[)roves  after  having  failed  to  do  so  under  other  lines  of  treatment,  (jne 
is  justified  in  attributing  the  loose  movements  to  intestinal  s>-philis. 
Mercury  prescribed  for  the  relief  of  intestinal  ulcerative  lesions  other 
than  luetic  invariably  aggravates  the  diarrheal  condition,  but  when 
the  loose  movements  are  caused  by  syphilitic  ulcers,  the  number  of 
daily  movements  begin  to  diminish  as  soon  as  the  physiologic  action 
of  the  drug  is  manifest.  In  this  class  of  cases  the  specific  treatment 
works  like  magic,  and  often  quickly  overcomes  a  persistent  diarrhea  of 
years'  standing  which  had  previously  been  considered  hopeless. 

The  diagnosis  of  syphilitic  diarrhea  is  comparatively  easy  to  make 
in  infants  and  children  who  have  inherited  lues  and  show  evidence  of 
it  in  deformed  teeth,  delayed  closure  of  the  fontanels,  enlarged  liver, 
spleen,  and  glands,  "snuffles,"  mucous  patches  about  the  mouth,  throat, 
vagina,  rectum  and  anus,  and  other  stigmata  of  congenital  syphilis. 

Again,  when  diarrhea  does  not  respond  to  dietary  and  therapeutic 
measures  effective  in  the  treatment  of  loose  movements  from  other 
gastro-intestinal  disorders  in  children  or  adults  who  exhibit  typic 
manifestations  of  congenital  or  acquired  lues — viz.,  chancre,  constitu- 
tional symptoms,  eruptions  of  the  skin  or  mucous  membranes,  lymph- 
oid enlargements,  falling  hair,  iritis,  or  tertiary  symptoms — the  pa- 
tient, in  all  probability,  is  suffering  from  a  luetic  enteritis  or  colitis. 
Ihi'  autlior  has  treated  patients  who  suffered  from  syphilitic  diarrhea 
which  was  complicated  by  entamebic  or  bacillary  infection,  which 
made  the  diagnosis  difficult. 

When  attempting  to  reach  a  diagnosis  in  cases  of  diarrhea  sup- 
posedly due  to  syphilis,  the  patient  should  be  stripped  and  carefully 


308      SYPHILITIC    ENTERITIS.    COLITIS.    ENTEROCOLITIS,    DIARRHEA    IN 

examined  to  find  out  if  he  has  external  signs  of  the  disease,  enlarge- 
ment of  the  spleen,  liver,  lymph-nodes,  or  a  fiat  saucer-like  swelling 
(gummatous  tumor)  auN-where  along  the  large  or  small  bowel.  One 
must  also  search  for  nodulated  swellings,  which  sometimes  indicate 
the  location  of  syphilitic  strictures,  because  in  such  cases  the  bowel 
is  sausage  shaped  and  feels  bogg>-  when  palpated. 

Spirochdta  pallida  (the  etiologic  factor  in  lues)  when  found  offers 
convincing  proof  that  the  patient  has  syphilis,  but  since  it  is  dis- 
coverable mainly  in  the  incipient  stage  of  the  disease,  and  is  sel- 
dom found  in  the  fecal  discharge  or  scrapings  from  syphilitic  intesti- 
nal lesions,  it  is  of  ver\-  little  or  no  importance  as  a  diagnostic  aid. 
and  cannot  be  depended  upon  to  help  differentiate  luetic  from  other 
inflammatory'  diseases  of  the  intestine. 

In  the  majority'  of  instances  it  is  the  later  lesions  of  syphilis  which 
induce  the  diarrhea,  and  spirochetes  are  seldom  found,  if  at  all.  in 
gummata  and  other  late  lesions  of  lues,  or  in  the  earlier  stages  of  the 
disease  where  the  patient  has  been  subjected  to  a  thorough  course  of 
antisyphilitic  treatment. 

Wassermanns  reaction  is  extremely  helpful  for  clearing  up  the 
diagnosis  in  cases  of  colitis  of  suspected  syphilitic  origin,  and  this  test 
is  more  important  than  Spirochaeta  pallida  as  a  diagnostic  aid. 

The  Wassermann  blood  reaction  is  not  infallible,  for  negative 
results  have  been  obtained  where  patients  had  syphilis  with  and 
without  having  undergone  antisyphilitic  treatment.  Positive  reac- 
tions have  also  followed  Wassermann's  test  in  other  diseases.  In  the 
vast  majority'  of  cases,  however,  when  one  or  more  positive  Wasser- 
mann's have  been  obtained,  one  is  justified  in  holding  that  the  patient 
has  syphilis;  and  that  he  has  not  when  tests  are  repeatedly  negative 
unless  the  patient  has  been  under  treatment.  Wassermann's  reaction 
is  valuable  during  the  treatment,  for  by  it  one  can  determine  when  to 
begin  or  stop  medication. 

The  Wassermann  serodiagnostic  reaction  is  of  little  use  to  the  busy 
practitioner  because  of  the  great  amount  of  care  and  time  required 
to  properly  prepare  for  and  carr\-  out  the  test,  which  should  be  done 
in  the  laboratory-. 

There  is  no  longer  any  question  that  lues  paves  the  way  both  for 
tuberculosis  and  cancer.  Certainly  these  distressing  ailments  occur 
in  syphilitic  subjects  with  a  frequency  which  cannot  be  otherv\'ise 
explained.  At  times  it  is  exceedingly  difficult  to  differentiate  a  tuber- 
cular from  a  syphilitic  diarrhea,  since  both  produce  almost  identical 
manifestations,  but  a  rational  diagnosis  can  be  made  when  sufficient 
time  is  taken  and  the  patient  is  carefully  examined  from  ever>-  stand- 
point. A  luetic  subject  gives  a  history-  of  having  suffered  from  one 
or  more  of  the  manifestations  of  the  disease,  his  color  and  general  ap- 
pearance are  comparatively  normal,  he  can  digest  his  food  fairly 
well,  and  has  sufficient  strength  to  attend  to  his  ordinan,-  duties,  while 
a  tubercular  subject  having  chronic  diarrhea  is  ver\-  ill.  has  a  sallow 
complexion,  is  emaciated  and  feeble,  has  poor  digestion,  runs  an  irreg- 


DIAGNOSIS  309 

ular  lemperature,  and  often  has  a  cougli,  laryn.u;itis,  hemoptysis,  rectal 
fistula,  or  other  indications  of  a  localized  tubercular  process  in  the 
respiratory  or  gastro-intestinal  tract,  manifestations  not  observed  in 
persons  suffering  from  intestinal  syphilis. 

The  number  of  evacuations  induced  by  tuberculosis  and  syphilis 
are  diminished  by  colonic  lavage,  but  patients  having  syphilis  respond 
more  quickly  to  antiluetic  treatment  than  tubercular  subjects  do  to 
other  therapeutic  measures.  In  syphilitic  diarrhea  mercury  has  a 
specific  action,  but  does  little  or  no  good  when  the  frequent  movements 
are  caused  by  tubercular  lesions  in  the  intestine;  and,  on  the  contrary, 
tubercular  subjects  do  well  when  placed  upon  Russell's  emulsion,  cod- 
li\-er  oil,  a  milk-and-egg  diet,  and  when  compelled  to  sleep  with  the 
windows  open  and  spend  their  time  in  the  open  air,  procedures  which 
do  little  or  no  good  toward  improving  the  condition  of  patients  suffer- 
ing from  syphilitic  diarrhea. 

In  both  tuberculosis  and  syphilis  of  the  small  bowel  and  colon 
diminutive  nodules  have  been  observed  in  the  peritoneal  and  other 
tunics  of  the  bowel  which  have  been  mistaken  the  one  for  the  other, 
but  such  swellings  are  encountered  very  much  more  frequently  and  in 
larger  numbers  in  tubercular  than  in  syphilitic  subjects.  Again,  in- 
tesiinal  lues  is  sometimes  present  as  saucer-shaped  infiltrates  of  large 
size,  originating  in  the  mucosa  or  submucosa.  Under  such  circum- 
stances, according  to  Brunner,  a  differentiation  can  be  made  between 
the  grayish-white  tubercles  of  tuberculosis  and  the  opaque  yellowish 
nodules  of  syphilis  by  inspecting  the  diseased  gut,  and,  in  the  living, 
by  ascertaining  if  there  is  a  general  lymphocytosis,  enlargement  of  the 
spleen,  inflammation  of  the  hepatic  veins,  or  other  frequent  manifes- 
tations of  constitutional  lues.  The  Wassermann  reaction  is  of  value 
in  this  class  of  cases  in  determining  whether  or  not  the  patient  has 
syphilis,  but  the  spirochetes  ha\e  no  diagnostic  value  here  because 
they  cannot  be  found  except  when  the  diarrhea  occurs  during  the  early 
stages  of  lues. 

Owing  to  the  fact  that  a  tul)erculin  reaction  may  be  obtained  IjuLIi 
in  luetic  and  tubercular  individuals  this  diagnostic  aid  is  not  to  be 
relied  upon  in  determining  the  cause  of  diarrhea  in  doubtful  cases. 

Melena  is  a  common  manifestation  of  congenital  intestinal  s\-philis. 
I'nder  such  circumstances  the  evacuations  may  be  black  from  retained 
l)lood  or,  in  exceptional  instances,  the  stools  contain  more  or  less 
briglit  red  bUxxl. 

Macroscopic  and  microscopic  examination  of  the  stools  is  of  great 
value  in  differentiating  between  the  \arious  diseases  causing  chronic 
diarrhea.  In  so  far  as  lues  is  concerned,  examination  of  the  feces  and 
discharges  is  negative.  Consequently,  when  the  subject  has  syphilis, 
and  neither  entameba  nor  dysenteric  l)a(illi  can  be  found  in  the  dis- 
charge to  account  for  the  condition,  a  tentati\e  diagnosis  of  syphilitic 
colitis  is  justifiable,  and  the  patient  should  be  given  saK'arsan  or  a 
course  of  mercurial  treatment,  which  rapidly  improves  his  condition 
when  lues  is  responsible  for  the  trouble. 


3IO      SYPHILITIC    ENTERITIS.    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

When  the  loose  movements  are  the  result  of  entamebic,  tubercular, 
or  gonorrheal  colitis  the  microscope  can  be  relied  upon  to  clear  up  the 
diagnosis  in  many  instances,  because  an  examination  of  the  scrapings 
and  discharge  from  the  ulcers  will  re\eal  the  entamebcC,  the  bacilli  of 
Shiga,  Flexner's  tubercle  baciHi,  or  Xeisser's  gonococci,  etc.  Micro- 
scopic examination  of  the  feces  is  also  of  assistance  in  clearing  up  the 
diagnosis  between  infectious  diseases  of  the  colon,  membranous  colitis, 
and  other  inflammatory  conditions  of  the  intestinal  mucosa.  Finally, 
W'ith  the  aid  of  test-meals  and  microscopic  examination  of  the  stools 
one  can  determine  the  presence  or  absence  of  undigested  food  remnants 
and  determine  whether  or  not  the  diarrhea  is  due  to  gastrogenic  or 
enterogenic  disturbances.  In  suspected  cases  of  gastrogenic  diarrhea 
the  stomach  contents  should  be  analyzed  to  determine  if  there  is  an 
absence  of  hydrochloric  acid  or  other  abnormality  of  the  gastric  juice 
which  might  be  responsible  for  the  loose  movements.  Now  and  then 
a  fecal  examination  will  also  indicate  that  the  disturbance  is  in  the 
liver  or  the  pancreas. 

Macro-  and  Microscopic  Findings. — It  is  not  difficult  to  distinguish 
between  lues  and  tuberculosis  of  the  bowel  when  a  segment  of  gut  can 
be  had  for  examination,  because  when  syphilis  is  the  cause  of  the 
trouble  one  or  more  extensive  flat  gummatous  swellings  are  usually 
present,  which  consist  largely  of  small  round-celled  infiltrations,  and 
involve  one  or  all  of  the  tunics  of  the  gut  and  frequently  include  the 
mesentery.  The  mucosa  may  show  a  few  or  many  superficial  or  deep 
crater-like  ulcerated  areas,  and  the  peritoneum  is  greatly  thickened 
and  attached  to  adjacent  loops  of  the  bowel  or  other  structures  by 
exudates  or  band-like  adhesions.  Diminutive  nodules  have  been 
observed  in  intestinal  syphilis,  but  usually  when  numerous  small  tuber- 
cles are  present  they  indicate  the  tuberculous  nature  of  the  disease, 
and  the  tissue  should  be  examined  microscopically  for  tubercle  bacilli 
and  giant  cells,  which,  when  found,  indicate  a  tubercular  process. 
Too  much  reliance,  however,  cannot  be  placed  upon  the  presence  of 
the  giant  cells,  since  a  few  writers  upon  syphilology  maintain  that  they 
are  to  be  found  in  the  syphilitic  tissue,  and  both  tuberculosis  and 
syphilis  have  been  known  to  attack  the  bowel  in  the  same  vicinity. 

Proctoscopic  and  sigmoidoscopic  examination  is  of  little  use  in 
determining  the  presence  or  absence  of  syphilis  in  the  small  intestine 
or  colon,  but  is  of  great  help  in  clearing  up  the  diagnosis  when  the 
disease  is  situated  in  the  lower  sigmoid  flexure  or  rectum,  because  when 
these  segments  of  gut  are  involved  in  the  luetic  process  the  inflamma- 
tion, ulceration,  or  stricture  responsible  for  the  chronic  diarrhea  can 
be  seen  and  studied  at  leisure. 

Blood  examinations  are  unreliable  when  differentiating  between 
tuberculosis,  syphilis,  dysentery,  and  other  ulcerative  lesions  of  the 
colon  inducing  chronic  diarrhea,  because  patients  suffering  from  these 
affections  are  usually  anemic  and  show  about  the  same  blood  changes 
as  regards  the  hemoglobin,  red  blood-cells,  and  leukocytes.  During 
the  earlier  febrile  stage  of  lues  a  lymphocytosis  is  generally  observable. 


PROGNOSIS  311 

but  this  is  of  little  if  any  assistance  in  clearing  up  the  diagnosis  in 
cases  of  chronic  diarrhea,  because  when  the  loose  movements  are  the 
result  of  lues  the  diarrhea  occurs  in  the  later  stages  of  the  disease 
after  the  lymphocytosis  has  disappeared. 

One  cannot  rely  upon  the  change  in  number  of  eosinophils  in  ihe 
diarrheas  mentioned,  but  they  are  of  diagnostic  value  in  cases  when 
the  parasitic  origin  of  the  disease  is  suspected,  because  in  certain  para- 
sitic affections  of  the  intestine  the  eosinophils  show  a  tendency  to  in- 
crease greatly  in  number. 

Urinary  analysis  is  seldom  of  diagnostic  value  in  this  class  of  cases. 
There  is  evidence  to  support  the  belief  that  lues  may  induce  a  pancrea- 
titis accompanied  by  sugar  in  the  urine,  which  rapidly  disappears  when 
the  patient  is  put  upon  anii>\  philiiic  treatment. 

Acquired  anorectal  syphilis  may  manifest  itself  in  the  form  of  a 
chancre,  catarrhal  proctitis,  stricture,  superficial  or  deep  ulcers. 

Chancres  and  the  fissures  of  congenital  lues  are  readily  detected 
by  separating  the  buttocks  and  inspecting  the  anus. 

ricers  can  be  detected  with  the  finger,  but  their  number,  size,  and 
condition  can  be  more  accurately  determined  1:)\'  inspecting  them 
through  the  proctoscope. 

The  location  and  characteristics  of  strictures  located  within  3  inches 
(7.5  cm.)  of  the  anus  can  be  ascertained  by  digital  examination,  but 
when  situated  higher  up  the  diagnosis  is  made  through  the  sigmoido- 
scope or  with  the  aid  of  Wales'  bougies,  neither  of  which  should  be  forced 
through  the  constriction  until  it  has  been  inspected  and  the  size  of  its 
caliber  determined,  because  many  deaths  from  rupture  and  peritonitis 
have  followed  the  introduction  of  instruments  through  stenoses  located 
about  the  peritoneal  attachment  to  the  rectum. 

Digital  examination  of  the  rectum  should  never  be  neglected  in  this 
class  of  cases,  because  ulcers,  syphilitic  excrescences,  and  strictures 
located  within  3  inches  (7.5  cm.)  of  the  anus  can  be  readily  detected 
with  the  finger  and  afterward  viewed  through  the  proctoscope. 

The  anus  and  perianal  skin  of  persons  suspected  of  having  syphilitic 
colitis  (diarrhea)  should  be  carefully  inspected,  for  if  the  patient  has 
colonic  or  rectal  lues  he  will  complain  of  anal  fissures  and  excoriations 
of  the  adjacent  skin  caused  by  the  acrid  discharge  passing  over  them. 

Finally,  when  a  patient  gives  a  history  of  having  had  a  chancre, 
falling  out  of  the  hair,  a  secondary  eruption,  sore  mouth  and  throat, 
or  has  the  stigmata  of  inherited  lues,  and  suffers  from  chronic  diarrhea, 
when  the  stools  contain  pus.  blood,  and  mucus,  and  ulcers  are  visible 
in  the  rectum  and  sigmoid  flexure  through  the  proctoscope,  one  is  per- 
fectly justified  in  making  a  diagnosis  of  syphilitic  colitis,  particularly 
when  the  stools  do  not  contain  entamebcC,  dysenteric  bacilli,  hel- 
minths, etc. 

The  prognosis  in  cases  of  syphilitic  diarrhea  is  favorable  in  some  and 
grave  in  other  instances,  depending  upon  the  type  of  the  luetic  lesions 
causing  the  troul)le  and  the  extent  to  which  they  have  progressed. 

Enteritis  syphilitica  is  not  a  serious  affection,  except  in  the  case 


312       SYPHILITIC    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

of  infants  and  old  and  debilitated  individuals.  Persons  suffering  from 
this  complaint  may  recover  spontaneously,  but  diarrhea,  when  per- 
sistent, is  always  more  quickly  controlled  by  combining  the  anti- 
svphilitic  with  dietary  and  other  therapeutic  measures  useful  in  over- 
coming intestinal  catarrh  and  ulceration. 

The  prognosis  in  this  class  of  cases  is  favorable,  since  the  disturb- 
ance in  the  mucosa  is,  probably,  similar  to  that  of  the  skin  in  the 
secondary  stage,  which  may  disappear  without  treatment.  In  the 
later  periods  of  intestinal  syphilis,  if  the  enteritis  has  become  chronic, 
specific  remedies  and  colonic  irrigations  can  be  relied  upon  to  heal  the 
lesions  and  diminish  or  arrest  the  frequent  movements. 

The  prognosis  is  always,  more  serious  when  the  bowel  is  involved 
to  a  considerable  extent  by  ulcerated  areas  or  gummata,  yet  under 
such  unfavorable  circumstances  antisyphilitic  treatment  nearly  always 
improves  the  patient's  condition  and  at  times  effects  a  permanent 
cure.  Elsewhere  the  author  has  reported  at  length  a  case  of  chronic 
diarrhea  induced  by  a  large  gumma  that  caused  almost  complete  ob- 
struction, yet  the  patient  made  a  complete  recovery  following  a  course 
of  specific  treatment,  and  he  has  also  succeeded  in  correcting  diarrhea 
incited  by  syphilitic  ulceration  of  the  intestine  in  the  same  way. 
When  the  luetic  process  has  produced  one  or  more  annular  cicatricial 
stenoses  of  the  bowel  as  the  ulcers  heal,  or  through  the  formation  of  a 
long  tubular  stricture  when  the  sclerotic  process  is  diffuse  and  in- 
volves the  entire  thickness  of  the  bowel,  antis\-philitic  remedies  are 
useless  because  they  will  not  cause  absorption  of  the  scar  and  other 
dense  tissues  in  and  about  a  constricted  segment  of  the  gut,  but 
they  minimize  or  arrest  the  luetic  process  in  other  parts  and  pre- 
vent the  formation  of  new  strictures.  When  the  bowel  is  partially 
or  completely  occluded  by  a  syphilitic  stricture  in  the  small  intes- 
tine or  colon  nothing  short  of  surgical  intervention  will  relieve  the 
diarrhea  and  other  symptoms  of  obstruction.  In  order  to  afford  relief, 
and  permit  the  patient  to  permanently  recover  or  obtain  relief  in  this 
class  of  cases,  it  is  necessary  either  to  (a)  remove  the  stenotic  gut,  (b) 
establish  an  artificial  anus  above  the  stricture,  or  (c)  exclude  the 
involved  segment  of  intestine  from  the  fecal  current,  all  of  which 
measures  the  author  has  practised  with  satisfaction  at  different  times. 

When  the  leutic  process  extensively  involves  both  the  small  and 
large  intestines,  and  deep  penetrating  ulcers  or  multiple  strictures  are 
present,  and  when  the  disease  has  extended  to  neighboring  organs 
or  has  resulted  in  the  formation  of  simple  or  fecal  fistula?  accom- 
panied by  copious  discharges,  temporary  relief  may  be  afforded  the 
patient,  but  the  prognosis  is  very  grave  and  it  is  only  a  question  of 
time  when  he,  largely  through  exhaustion,  must  succumb  to  the  disease. 

Extirpation  of  the  diseased  bowel  affords  immediate  relief,  but  when 
the  patient  still  suffers  from  enteritis  syphilitica  or  luetic  ulceration 
of  the  large  intestine,  colonic  irrigations  and  antisyphilitic  treatment 
must  be  continued  following  operation  until  these  conditions  have  been 
corrected,  or  the  relief  obtained  will  be  of  short  duration. 


CHAPTER   XXVII 

SYPHILITIC    ENTERITIS,    COLITIS,    AND    ENTEROCOLITIS 
(INTESTINAL    SYPHILIS),    DIARRHEA    IN    {Concluded) 

TREATMENT 

MEDICINAL    (INCLUDING    SALVARSANi,  SURGICAL 

Medicinal  Treatment. — The  medical  treatment  of  intestinal  luetic 
lesions  (Fig.  47)  causing  loose  movements  should  be  the  same  as  that 
employed  in  the  treatment  of  syphilitic  lesions  involving  other  parts 
of  the  body,  except  that  it  should  be  reinforced  by  colonic  irrigations. 
Here  we  have  nothing  to  do  with  the  prophylactic  and  preventive 
treatment  of  lues,  because  the  opportunities  for  this  have  long  since 
passed  in  this  class  of  cases. 


Fig.  47. — Sj'philitic  coloproctitis  complicated  by  extensive  anov'ulvar  ulceration. 

More  can  be  accomplished  with  tlrugs  in  the  treatment  of  syphilitic 
than  in  tubercular,  helminthic,  dysenteric,  oran\-  other  type  of  ulcera- 
tive colitis  causing  diarrhea.  The  usefulness  of  the  antisyphilitic 
treatment  has  been  demonstrated  many  times  by  the  author  in  con- 
genital and  acqtiired  syphilis  in  cases  where  diarrhea  had  been  incited 
by  syphilitic  inflammation  or  ulcers  of  the  intestine  and  gummata  caus- 
ing the  obstruction. 

From  time  to  time  various  adjuvants  and  substitutes  for  mercury 
and  the  iodid  of  potassium  have  been  suggested  by  syphilographers, 

313 


314      SYPHILITIC    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

some  of  which  are  probably  more  easy  to  employ,  but  their  curativ^e 
action  is  not  superior  to  that  of  the  older  drugs.  Of  the  newer  medi- 
cines recommended  in  the  treatment  of  intestinal  and  other  syphilitic 
lesions  are  arsacetin,  atoxyl,  soamin,  kharsin,  and  asodyl,  which  belong 
to  the  arsenic  group.  These  agents  are  of  assistance  in  minimizing 
the  effect  of  the  virus  and  in  toning  up  the  system,  but  it  is  question- 
able if  they  have  the  specific  action  attributed  to  the  remedies  usually 
emploved  in  the  treatment  of  lues.  Because  of  their  non-specific  ac- 
tion in  this  class  of  cases  and  their  tendency  to  accumulate  in  the  body 
in  toxic  amounts  and  produce  distressing  and  dangerous  manifesta- 
tions— viz.,  migraine,  deafness,  dizziness,  blindness,  and  retention  of 
urine — they  should  not  take  the  place  of  mercury  and  the  iodids,  but  if 
employed  to  reinforce  these  remedies  they  should  be  given  in  smaller 
quantities.  Of  the  arsenic  compounds,  atoxyl  and  arsacetin  are  the 
most  reliable,  and  the  best  results  are  obtained  when  they  are  given  in 
5-  to  8-gr.  (0.30-0.50)  doses  every  other  day  for  two  weeks,  then  dis- 
continued for  the  same  length  of  time,  when  again  administered  for 
a  like  period.  The  treatment  should  be  continued  in  this  way  until 
the  desired  results  are  obtained. 

Debilitated  and  anemic  syphilitic  subjects  do  better  when  the  spe- 
cific treatment  is  reinforced  by  dietetic  measures — tonics,  a  change 
of  surroundings,  hydrotherapy,  mild  forms  of  electricity,  or  exercise 
in  the  open  air.  The  usual  tonics — arsenic,  iron,  cod-liver  oil,  Russell's 
emulsion,  etc. — are  useful  for  upbuilding  the  patient's  general  health, 
but  for  arresting  hemorrhages  of  the  mucosa  and  skin  we  have  no  more 
reliable  remedy  than  calcium  chlorid,  grs.  x  to  xx  (0.60-1.30),  adminis- 
tered three  times  daily. 

Salvarsan  (Ehrlich)  is  extensively  employed  in  the  treatment  of 
syphilis,  because  with  it  one  can  in  a  few  days  destroy  spirochetes 
and  alleviate  symptoms  which  would  by  the  older  or  mercurial  potas- 
sium treatment  require  months  to  accomplish. 

When  employed  shortly  following  infection  it  causes  chancres  to 
disappear  and  forestalls  later  manifestations.  It  is  reliable  in  the 
first  and  second,  helpful  in  tertiary,  but  is  of  little  use  in  the  destructive 
or  terminal  stage  of  syphilis,  except  when  employed  in  conjunction 
with  potassium  iodid  or  iodipin.  A  cure  may  be  effected  h\  a  single 
large  dose,  but  better  results  obtain  when  salvarsan  is  repeated  in 
smaller  amounts  covering  a  period  of  from  three  to  six  weeks,  and  when 
the  initial  dose  is  followed  by  mercurial  treatment.  In  the  later 
stages  of  the  disease,  where  lues  is  destructive,  causing  infiltrates  or  im- 
pairing the  walls  of  blood-vessels  which  would  lead  to  necrosis  of  the 
tissues,  salvarsan  is  best  reinforced  by  the  iodids,  which  help  to  arrest 
the  process  and  favor  absorption  of  the  deposits. 

Absorption  follows  when  salvarsan  is  injected  beneath  the  skin 
into  the  muscles  or  veins,  but  the  intravenous  method  is  preferable  be- 
cause it  induces  less  pain,  is  seldom  followed  by  sequela?,  and  gives 
quicker  and  better  results.  This  procedure  must  be  practised  with 
the  care  observed  in  other  operations,  and  the  patient  should  remain 


MEDICINAL    TREATMENT  315 

in  the  house  for  at  least  a  day,  otherwise  infection  or  serious  compli- 
cations may  follow.  When  properly  administered  in  suitable  doses  the 
reaction  and  subsequent  symptoms  are  unimportant,  but  when  the 
remedy  is  carelessly  prepared  or  injected,  or  is  given  in  ver\'  large 
doses,  the  patient  sometimes  complains  of  vertigo,  gastric  disturbances 
and  diarrhea,  high  temperature,  convulsions,  and  death  have  some- 
times occurred. 

Elimination  begins  in  from  thirty-six  to  forty-eight  hours,  and  the 
late  effects  of  salvarsan  are  irritation  of  the  kidneys,  transitory-  albu- 
minuria, acute  nephritis,  gastro-intestinal  irritability,  and  occasion- 
ally the  organs  of  special  sense  have  been  affected  and  blindness  or 
deafness  has  followed  the  treatment,  complications  thought  to  have 
been  caused  more  by  the  disease  than  the  remedy. 

The  treatment  should  be  continued  for  weeks  or  months  until  the 
spirochetes  have  disappeared  and  Wassermann's  blood  reactions  are 
repeatedly  negative.  Injections  should  subsequently  be  made  when 
spirilla  are  discovered  or  the  patient  exhibits  a  positive  Wassermann. 
A  single  injection  may  be  employed  in  the  symptomatic,  but  repeated 
doses  are  necessar\-  in  the  curative  treatment  of  intestinal  lues  or  else- 
where. 

The  average  dose  is  gr.  x  (0.60)  for  men  and  gr.  viiss  (0.50)  for 
women,  and  should  be  repeated  as  weekly  injections,  extending  o\'er 
a  period  of  from  three  to  five  weeks.  For  children  eight  years  old 
and  upward  gr.  v  (0.30)  is  the  usual  amount,  while  the  dose  for  infants 
having  inherited  syphilis  is  from  gr.  |  (o.oij  to  gr.  |  (0.02). 

Salvarsan  is  unreliable  in  the  treatment  of  syphilis  complicated  by 
tabes  or  paresis. 

Patients  afflicted  with  syphilitic  colitis  nearly  always  improve 
following  salvarsan  injections,  but  this  remedy  is  inefifective  in  this 
class  of  cases  except  when  reinforced  by  medicated  colonic  irrigations 
which  cleanse  the  inflamed  and  ulcerated  mucosa  of  feces,  toxins,  and 
irritating  discharges,  thur-  minimizing  the  part  pla\"ed  b\"  mixed  infec- 
tion. 

Xeosalvarsan  (a  condensation  of  saKarsan  and  sodium  formaldehyd 
sulphoxylate  from  Ehrlich's  laboratory)  is  better  tolerated,  causes 
less  reaction,  and  appears  to  be  as  effective  as  salvarsan.  The  indica- 
tions for  and  technic  of  administering  neosalvarsan  are  the  same  as 
for  salvarsan,  and  the  dose  for  men  is  gr.  xiij  to  xv  fo. 75-0. 90).  and 
for  women,  gr.  x  to  xiij  ('0.60-0.75). 

Mercury  and  potassium  iodid,  alone  or  in  combination,  barring 
salvarsan,  are  the  remedies  par  excellence  in  the  treatment  of  intestinal 
and  other  luetic  lesions  encountered  in  the  various  stages  of  syphilis. 
Mercur\-  and  the  iodids  have  a  specific  action  in  most  instances,  but 
now  and  then  patients  suffering  from  congenital  or  acquired  syphilis 
with  chronic  diarrhea  go  from  bad  to  worse  under  antisyphilitic  treat- 
ment, both  when  it  is  instituted  in  the  earlier  and  later  stages  of  the 
disease. 

Syphilitic  diarrhea  nearly  always  occurs  in  the  later  stages  of  lues. 


3l6      SYPHILITIC    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

and  because  of  this  it  is  advisable  to  place  the  patient  on  the  com- 
bined mercury  and  potassium  iodid  treatient  at  once  to  arrest  the 
disease  and  favor  healing  of  the  inflamed  and  ulcerated  mucosa  or  the 
absorption  of  gummatous  infiltrations  when  present.  The  dosage  of 
these  drugs  must  necessarily  be  varied,  for  some  syphilitic  subjects 
can  stand  them  in  larger  quantities  and  for  a  much  longer  time  than 
others.  Few  persons  can  take  mercury  or  the  iodids  alone  or  com- 
bined for  months  or  years  without  suffering  seriously  from  constitu- 
tional manifestations  caused  by  them.  Consequently,  it  is  advisable 
to  administer  these  remedies  for  a  time  (two  to  three  months)  and  then 
to  discontinue  them,  according  to  indications,  for  from  two  to  six 
weeks,  after  which  they  may  be  renewed  and  continued,  according  to 
this  alternating  plan,  as  long  as  may  be  necessary.  In  the  later 
stages,  as  their  influence  upon  the  disease  becomes  more  and  more 
manifest,  the  periods  of  active  treatment  should  be  shortened  and  those 
of  rest  lengthened. 

Considerable  care  is  necessary  when  administering  these  drugs  to 
persons  having  syphilitic  diarrhea,  because  both  mercury  and  the 
iodids  are  inclined  to  irritate  the  mucosa  under  favorable  circum- 
stances, and  when  strongly  pushed  in  this  class  of  cases  they  usually 
aggravate  the  intestinal  trouble  and  augment  diarrhea. 

Potassium  iodid  is  usually  given  internally,  because  when  injected 
beneath  the  skin  it  is  irritating  and  frequently  causes  abscess. 

When  potassium  iodid  is  given  by  mouth  the  patient  should  be 
instructed  to  begin  with  nu  lo  (0.60  c.c.)  of  a  saturated  solution  of  the 
salt  three  times  daily,  and  increase  the  dose  one  or  more  drops  daily 
until  the  physiologic  effects  of  the  drug  are  produced,  when,  after  a 
short  period,  the  dose  should  be  gradually  diminished  or  the  drug 
discontinued  for  a  time.  The  author  has  known  potassium  iodid  to 
work  wonders  in  cases  of  syphilitic  ulceration  complicated  by  persistent 
diarrhea,  and  has  treated  one  patient  for  an  extensive  gummatous 
infiltration  causing  obstruction  of  the  bowel  who  was  completely 
cured  by  this  agent,  and  in  two  other  instances  he  has  greatly  reduced 
the  size  of  gummatous  swellings  involving  the  intestine.  In  these 
cases  no  mercury  was  given,  and  the  good  results  were  attributed  solely 
to  the  potassium  iodid,  though  the  sufferers  had  taken  antisyphilitic 
treatment  before  they  came  to  him.  Mercury  exerts  a  beneficent 
influence  in  arresting  and  preventing  extension  of  the  luetic  process,  but 
it  is  not  so  reliable  as  potassium  iodid  for  hastening  the  absorption  of 
inflammatory  exudates  and  gummatous  tumors  of  the  gut. 

lodipin  (combination  of  iodin  chlorid  on  sesame  oil),  made  in  two 
strengths,  10  and  25  per  cent.,  is  practically  as  effective,  and  is  a  good 
substitute  for  iodids  in  the  treatment  of  syphilis,  because  it  can  be 
administered  for  a  longer  time  without  producing  iodism. 

The  author  has  obtained  good  results  in  the  treatment  of  syphilitic 
colitis  from  the  10  per  cent,  preparation,  administering  it  in  5j  to  5iij 
(4-12  c.c.)  doses  three  to  four  times  daily,  and  the  25  per  cent,  solu- 
tion when  30  to  90  nu  (2-6  c.c.)  were  injected. 


MEDICINAL    TREATMENT  317 

There  is  also  a  solid  preparation  of  iodipin  (containing  10  per  cent, 
of  iodin)  which  is  usually  prescribed  two  to  three  times  daily  in  30-gr. 
(2.0)  doses.  The  drug  should  be  continued  until  its  full  physiologic 
action  is  obtained. 

Mercurial  preparations  can  be  relied  upon  in  the  treatment  of 
syphilitic  lesions  of  the  intestine  causing  diarrhea  excepting  gummata. 
Mercury  may  be  administered  by  mouth,  inunction,  hypodermically, 
fumigation,  intravenously,  or  in  the  form  of  a  suppository,  but  of  these 
methods  the  first  three  named  are  the  most  reliable. 

Formerly  mercury  was  prescribed  in  the  form  of  a  tablet  or  pill, 
but,  owing  to  the  tendency  of  the  drug  to  cause  gastro-intestinal  dis- 
turbances when  administered  by  mouth,  many  physicians  now  give  it 
in  the  form  of  an  inunction  or  inject  it  beneath  the  skin  or,  preferably, 
into  the  muscles.  Mercury,  in  the  following  forms  and  dosage,  has 
been  successfully  employed  at  various  times  in  the  treatment  of  s}'ph- 
ilis  involving  the  intestine  or  other  organs,  viz.,  bichlorid  of  mercury, 
gr.  ^2  to  I  (0.002-0.008);  biniodid  of  mercury,  gr.  5V  to  iV  (0.0012- 
0.006);  protiodid  of  mercury,  gr.  i  to  f  (0.01-0.02);  and  tannate  of 
mercury,  gr.  j  to  ij  (0.065-0.13).  When  the  preparations  named  do 
not  meet  the  indications  or  disagree  with  the  patient,  a  blue  pill,  calo- 
mel, or  the  peptonate,  sozoiodolate,  carbonate,  or  salicylate  of  mercury 
may  at  times  be  substituted  for  them.  Many  syphilographers  prefer 
mercury  as  an  inunction,  and  the  favorite  preparations  for  this  pur- 
pose are  the  oleate  and  blue  ointment.  The  former  is  liked  best  by 
fastidious  patients,  since  it  does  not  discolor  the  linen,  but  larger  quan- 
tities of  the  oleate  are  required  because  it  is  weaker.  These  oint- 
ments may  be  applied  to  any  part  of  the  body,  but  regions  devoid  of 
hair  should  be  selected,  because  rubbing  in  of  the  ointment  causes  less 
discomfort  and  there  is  less  danger  of  infection  and  furunculosis  where 
hair-follicles  are  few. 

The  inunction  is  best  made  at  the  inner  or  outer  sides  of  the  thighs, 
arms,  the  abdomen,  and  back.  Preferably  the  inunction  should  be 
driven  in  immediately  following  a  hot  bath  while  the  pores  of  the  skin 
are  open,  which  explains  why  syphilitic  subjects  who  take  treatment  at 
the  various  hot  springs  improve  rapidly.  After  the  rubbing  at  night 
the  patient  should  retire,  and  next  morning  remove  all  evidences  of 
the  ointment  by  bathing  the  parts  with  dilute  alcohol  or  hot  water. 
The  treatments  usually  consume  from  twent\'  minutes  to  half  an  hour 
and  should  be  given  three  times  weekly  or  more  frequently,  and  con- 
tinued for  one  to  three  months  at  a  time. 

Preferably,  mercury  should  be  administered  1)\-  the  injection 
method,  because  the  treatment  is  cleanly,  inconveniences  the  patient 
but  little,  causes  but  slight  pain,  is  rarely  followed  by  gastro-intestinal 
disturbances,  one  can  accurately  measure  the  amount  administered, 
and  the  action  of  the  drug  is  more  lasting.  An  ordinary  glass  syringe, 
fitted  with  a  gold  or  platinum  needle,  can  lie  used,  but  the  needle  should 
have  a  large  bore  when  gray  oil  or  I,ami)kin's  cream  is  used.  The 
salicylate  and  bichlorid  are  more  often  employed  than  other  prepara- 


31 8      SYPHILITIC    ENTKRITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

tions  of  mercur\-,  and  the  injections  cause  less  trouble  and  give  better 
results  when  made  into  the  gluteal  muscle.  The  treatments  should  be 
made  once  a  week  or  at  longer  intervals  when  they  disturb  the  patient, 
and  for  as  long  a  time  as  may  be  required.  Pain  from  them  may  be 
minimized  by  combining  the  drug  with  eucain  or  cocain.  The  average 
dose  of  the  salicylate  of  mercury  is  gr.  f  (0.045),  but  the  amount 
should  be  increased  when  there  are  destructive  lesions  in  the  bowel 
and  administered  at  least  three  times  weekly.  When-  salivation  and 
irritation  of  the  gastro-intestinal  tract  and  kidneys  become  alarming, 
the  quantity  of  the  drug  should  be  reduced  or  it  should  be  discon- 
tinued. 

In  cases  where  tuberculosis  attacks  the  intestine  of  a  syphilitic 
subject  the  succinate  of  mercury  should  take  preference  over  the  mer- 
curial preparations  above  mentioned. 

For  the  convenience  of  the  busy  practitioner  the  author  has  in- 
corporated below  a  few  formulae  of  known  value  in  the  treatment  of 
luetic  diarrhea  and  other  manifestations  of  syphilis.  Most  of  them 
include  the  mixed  treatment  in  some  combination,  for  mercury  alone 
is  rarely  indicated,  since  persons  suffering  from  luetic  diarrhea  have 
usually  passed  the  early  stages  of  the  disease  and  require  both  mercury 
and  the  potassium  iodid.  The  dosage  of  the  formulae  given  may  be 
increased  or  decreased  according  to  the  necessities  of  the  individual 
case. 

I^.     Hydrargyri  iodidi  flavi gr.  xvj  (  i.oo  gm.); 

Ferri  et  quininae  citratis 5iij  (12.00  c.c); 

Extracti  hyoscyami gr.  xij  (  0.75  gm.). — M. 

Divide  into  pilulas  Xo.  Ix. 
Sig. — One  pill  three  times  daily. 

I^.     Hydrargyri  iodidi  rubri gr.  j-iij  (0.065-0.195  gm.); 

Potassii  iodidi 5ss-iss  (  15-45  c.c); 

Tincturae  cinchonas  compositae oiij  (9°  c.c); 

.\qu£e qs.  ad.  oi^'  (120  c.c). — M. 

Sig. — Teaspoonful  three  times  a  day. 

^.     Hydrargyri  chloridi  corrosivi gr.  j-ij  (0.065-0.13  gm.; 

Potassii  iodidi 5v  (20  c.c); 

Ferri  et  ammonii  citratis oj  (4  c.c); 

Tincturae  nucis  vomicae oiis  (10  c.c); 

Tincturae  gentianas  compositae q.  s.  ad.  §iv  (120  c.c).  — M. 

Sig. — Teaspoonful  three  times  a  day. 

I^.     Hydrargyri  chloridi  corrosovi gr.  j-ij  (0.065-0.13  gm.); 

Potassii  iodidi oijss  (10  c.c); 

Fluid  extracti  sarsaparillae o'j  (60  c.c). 

Or, 

Syrupi  sarsaparillae  compositae 5iv  (120  c.c). 

.\quae q.  s.  ad. — M. 

Sig. — Teaspoonful  three  times  a  day. 

Surgical  Treatment. — When  antisyphilitic  treatment  and  other 
therapeutic  measures  heretofore  recommended,  reinforced  by  medi- 
cated colonic  irrigations,  fail  to  heal  luetic  lesions  in  the  bowel  and  re- 


SURGICAL    TREATMRXT  319 

lieve  chronic  diarrhea,  surgical  intervention  is  imperative  if  the  patient 
is  to  be  permanently  cured.  Operations  may  be,  but  are  not  always, 
efifective,  since  fr((|ueiuly  a  postoperative  course  of  treatment  is 
necessary  to  complete  the  cure.  When  the  bowel  is  highly  ulcerated, 
diarrhea  is  persistent,  the  stools  contain  considerable  pus,  blood,  and 
mucus,  and  the  patient  suffers  severely  from  intestinal  auto-intoxication 
and  infection,  appendicostomy  (see  Fig.  159),  cecostomy  (sec  Fig.  164),  or 
the  author's  enterocecostomy  (see  Fig.  164)  are  indicated,  because  in 
such  cases  the  colon  is  highh-  inflamed  and  ulcerated  and  nothing  short 
of  through-and-through  bowel  irrigations  will  heal  the  lesions  and 
relieve  the  patient.  Subsequent  to  the  establishment  of  an  inlet  above, 
by  inserting  a  proctoscope  the  fluid  can  be  made  to  enter  the  appendix 
or  cecum,  and  readily  find  its  way  through  the  colon  and  out  at  the 
anus,  and  in  doing  so  dislodges  and  washes  out  toxins,  food  remnants, 
irritating  feces,  and  acrid  discharges.  Better  results  are  obtained 
when  the  patient's  position  is  changed  from  time  to  time  during  the 
treatment  to  insure  the  fluid  reaching  all  sides  of  the  diseased  gut. 
Strong  irrigants  are  required  when  lesions  are  numerous  and  extensive, 
but  their  strength  is  best  reduced  as  healing  takes  place,  which  is  indi- 
cated by  the  diminished  number  of  evacuations  and  amount  of  pus, 
blood,  and  mucus  in  the  stools.  The  colon  should  be  washed  out 
once  or  twice  daih'  in  aggravated  cases,  but  as  the  condition  improves 
colonic  flushings  need  not  be  made  more  than  three  times  weekly. 

When  the  movements  are  extremely  foul,  an  ichthyol  (5  per  cent.) 
or  a  hydrogen  peroxid  (10  per  cent.)  solution  can  be  relied  upon  to 
disinfect  the  intestine  and  relieve  symptoms.  In  the  average  case 
boric  acid  (3  per  cent.),  ichthyol  (2  per  cent.),  potassium  permanga- 
nate (i  per  cent.),  and  protargol  (5  per  cent.)  irrigating  solutions  are 
effective,  but  w^hen  diarrhea  is  persistent  and  the  discharge  is  abun- 
dant, their  strength  should  be  increased.  There  are  many  other  effect- 
ive irrigants  which  one  can  employ  following  appendicostomy  and 
cecostomy  in  the  treatment  of  syphilitic  and  other  forms  of  ulcerative 
colitis,  but  these  and  the  technic  of  their  administration  have  been 
given  in  Chapter  XLI,  devoted  to  Colonic  Irrigations  and  Enemata. 

Before  the  advent  of  appendicostomy  and  cecostomy,  enterostomy 
and  colostomy  were  occasionally  resorted  to,  but  they  have  been  aban- 
doned because  patients  object  to  having  their  feces  discharged  through 
the  side,  and  because  a  second  and  dangerous  operation  is  necessary 
to  close  the  artificial  anus  after  the  lesions  have  healed. 

Intestinal  {colonic)  exclusion  (see  Figs.  177,  178,  181)  is  sometimes 
practised  as  a  substitute  for  appendicostomy  and  cecostomy,  or  is 
resorted  to  following  these  procedures  where  the  lesions  have  not  healed 
to  exclude  the  inflamed  and  ulcerated  segment  of  intestine,  so  that  it  will 
have  an  opportunity  to  rest  and  not  be  constantly  traumatized  by 
the  feces.  The  author  has,  in  a  number  of  instances,  succeeded  in 
curing  patients  afflicted  with  syphilitic,  catarrhal,  and  other  forms  of 
infectious  colitis  by  this  procedure.  In  some  cases  only  a  short  piece 
of  the  gut  was  shut  off,  but  usually  the  ileum  was  severed  near  the 


2,20      SYPHILITIC    ENTERITIS,    COLITIS,    ENTEROCOLITIS,    DIARRHEA    IN 

cecum,  and  after  both  extremities  had  been  closed  the  proximal  end  was 
anastomosed  with  the  sigmoid  flexure  or  rectum  (ileosigmoidostomy, 
ileorectostomy) . 

Unilateral  (see  Fig.  i8i)  and  bilateral  (see  Fig.  177)  exclusion  have 
been  resorted  to,  but  the  former  is  indicated  more  frequently  than  the 
latter  when  the  5/;?a//  intestine,  cecum,  colon,  sigmoid,  or  rectum  are 
extensively  inflamed,  ulcerated,  or  blocked  by  strictures. 

When  less  radical  measures  fail  to  relieve  or  cure  the  patient  the 
diseased  gut  should  be  resected  or  extirpated,  the  procedures  for  which, 
named  according  to  the  segment  of  gut  to  be  removed,  are  designated 
enterectomy,  cecectomy,  colectomy,  sigmoidectomy,  or  proctectomy.  Where 
stenoses  are  located  in  the  lower  3  inches  (7.5  cm.)  of  the  rectum  or 
below  the  peritoneal  reflection,  and  the  patient  prefers  a  palliative  to 
a  radical  or  curative  operation,  the  lumen  of  the  strictured  bowel  can 
be  quickly  increased  by  forcible  divulsion  or  proctotomy  {internal  or 
external)  procedures,  which  are  dangerous  when  the  stenosis  is  in  the 
upper  rectum.  For  a  description  of  the  indications  for  the  above- 
mentioned  surgical  procedures  the  reader  is  referred  to  the  chapters 
devoted  to  the  surgical  treatment  of  Diarrheal,  Catarrhal,  and  Para- 
sitic Diseases. 

In  concluding  this  chapter  the  author  wishes  to  express  his  indebt- 
edness to  the  works  and  publications  of  J.  Brunner,  Power  and  Murphy, 
Birch-Hirschfeld,  Czerny,  Fournier,  Ehrlich,  Frankel,  Jullien,  Klein- 
schmidt,  Oser,  Hayem  and  Tissier.  and  Levaditi  and  Roche,  the  lead- 
ing authorities  upon  intestinal  syphilis. 


CHAPTER   XXVIII 

ENT AMEBIC    COLITIS    (ENT AMEBIASIS,    ENT AMEBIC    DYS- 
ENTERY),  DIARRHEA   IN 

DEFINITION,  GENERAL  REMARKS,  HISTORY,  ETIOLOGY,  GEOGRAPHIC 
DISTRIBUTION,  MORPHOLOGY,  CULTURE  AND  CLASSIFICATION 
OF  ENTAMEBA 

Definition. — Entamebic  colitis  (dysentery)  is  a  sporadic  or  endemic 
infectious  disease  of  the  colon  (and  sometimes  terminal  ileum)  charac- 
terized anatomically  by  marked  inflammatory  and  ulcerative  lesions 
in  the  mucosa,  clinically  by  frequent  fluid  stools  containing  an  abun- 
dance of  mucus,  blood,  and  at  times  pus,  and  subjectively  by  abdom- 
inal pain,  tenesmus,  and  constitutional  manifestations,  as  prostration, 
anorexia,  and  fever. 

The  author  is  aware  that  this  definition  is  unsatisfactory,  as  would 
be  all  others  which  attempted  in  a  single  sentence  to  explain  what  is 
understood  by  various  investigators  as  dysentery. 

One  might  as  well  attempt  to  get  up  a  single  definition  which  would 
define  scarlet  fever,  whooping-cough,  chicken-pox,  etc.,  as  to  seek  to 
accomplish  the  same  for  dysentery,  because  of  its  variegated  etiology, 
changeable  intestinal  pathology,  and  the  dissimilar  manifestations  in 
difterent  forms  of  the  disease. 

General  Remarks. — Two  decades  ago  this  aftection  was  believed 
to  be  constitutional,  but  we  now  know  that  it  originates  within  the 
bowel  (from  Entama^ba  histolytica),  and  when  general  disturbances 
arise  they  are  secondary  to  local  infection  in  the  colon  and  exceptionally 
the  lower  ileum. 

Until  a  few  years  ago  the  term  "dysentery"  was  universally  applied 
to  all  bowel  disturbances  represented  by  the  symptom-complex — viz.. 
frequent  bloody  evacuations  contaifiing  mucus,  with  abdominal  pain  and 
rectal  tenesmus — and,  unfortunately,  the  custom  still  obtains  in  some 
quarters. 

The  practice  of  regarding  bowel  afi'ections  accompanied  by  these 
symptoms  as  dysentery  has  led  to  great  confusion  and  improper  treat- 
ment, because  the  term  means  nothing  from  an  etiologic  or  pathologic 
standpoint. 

Small  intestinal  aft'ections  are  rarely  accompanied  b\'  these  mani- 
festations, but  there  are  many  diseases  of  the  colon,  sigmoid  flexure, 
and  rectum,  as  non-specific  (catarrhal),  tubercular,  s\-phililic,  and 
gonorrheal  colitis,  in  addition  to  the  so-called  dysenteric  group  (enta- 
mebic, bacillary,  flagellate,  ciliate  and  coccidic,  and  helminthic  colitis), 
any  and  all  of  which  may  augment  the  number  of  evacuations,  cause 
21  321 


322  ENTAMEBIC    COLITIS,    DIARRHEA    IN 

Straining,  the  discharge  of  blood  and  mucus,  and  incite  locaHzed  in- 
testinal or  general  abdominal  soreness,  pain,  and  tenderness  upon 
pressure. 

Formerly  patients  might  have  suffered  long  and  severely  from  any  of 
these  affections,  and  a  diagnosis  of  dysentery  would  not  have  been 
thought  of  until  the  dysenteric  symptom-complex  became  manifest, 
when  instantly  it  would  be  diagnosed  as  such. 

With  our  present  knowledge  it  seems  to  the  author  that  it  is  time 
to  stop  calling  intestinal  affections  accompanied  by  the  above  symp- 
tom-complex dysentery,  and  classify  them  according  to  their  etiology 
and  permit  the  word  dysentery  to  become  obsolete. 

Since  colitis — slight,  moderate,  or  severe — represents  the  chief 
organic  change  in  most,  if  not  all,  bowel  disturbances  accompanied  by 
diarrhea,  mucus,  pus,  and  blood  in  the  stools,  tenesmus,  meteor  ism, 
and  abdominal  discomfort  or  pain,  the  author  would  suggest  that,  as  a 
means  of  designating  the  various  affections  of  this  class,  the  term 
colitis  be  employed  with  the  etiologic  factor  in  the  disease  used  as  a 
prefix. 

Such  a  grouping  seems  practicable  because  the  name  would  then 
mean  something,  since  it  would  convey  an  idea  as  to  the  etiolog>-, 
pathology,  and  symptomatology,  and  indicate  the  treatment  of  the 
intestinal  condition  (colitis)  referred  to. 

Based  upon  this  understanding,  inflammatory  and  ulcerative 
lesions  of  the  colon  could  then  be  classified,  for  example,  as  (a)  a  non- 
specific {catarrhal)  colitis;  (b)  tubercular  colitis;  (c)  syphilitic  colitis; 
(d)  gonorrheal  colitis;  (e)  bacillary  colitis;  (/)  entamebic  colitis;  (g)  hel- 
minthic and  halantidic  colitis,  coccidial  colitis,  and  flagellatic  colitis. 

Organisms  Associated  with  the  Specific  Agents  of  Dysenteric 
Colitis. — It  has  been  stated  elsewhere  that  bacilli  of  the  colon  group, 
streptococci,  and  other  forms  of  intestinal  bacteria  have  been  fre- 
quently encountered  as  causal  or  aggravating  factors  with  the  specific 
agents  (entamebee  and  bacilli)  of  colitis  (dysenteric),  and  here  the  author 
w^ishes  to  call  attention  to  other  parasites  and  organisms  which  have 
been  found  associated  more  or  less  frequenily  with  different  types  of 
the  disease. 

Anderson^  investigated  the  convicts  at  Port  Blair  to  determine  how 
many  of  them  harbored  intestinal  protozoa.  He  studied  920  of  the 
2539  cases  of  dysentery  admitted  to  the  hospital  during  1905,  and  found 
that  amebse  were  associated  with  flagellates  (trichomonas  and  lamblia) 
in  455  instances,  and  that  the  latter  were  present  in  29  cases  where 
ameb?e  were  absent.  Balantidium  coli  were  observed  in  combination 
with  flagellates  and  amebae  four  times;  alone,  once.  Of  210  individuals 
afflicted  with  other  ailments,  in  7  there  were  amebae,  in  54  ameba;  and 
flagellates,  and  in  80  flagellates  onh  ,  which  gives  one  an  idea  as  to  the 
frequency  with  which  protozoa  are  harliored  within  the  bowel  in  dis- 
tricts where  entamebiasis  is  endemic — and  no  doubt  protozoa  fre- 
fluentK-  complicate  bacillary  colitis.  The  author  has  treated  several 
'  Brit.  Med.  Jour.,   igo8,  vol.  ii,  p.   1224. 


HISTORIC    NOTE  323 

patients  who  harbored  dyseiUerie  bacilli  or  entamelxe  and  helminths 
(tape-,  round,-  or  pin-worms). 

Historic  Note. — Dysentery  has  attracted  the  allenlion  (jf  medical 
men  almost  continuously  since  it  was  first  described  by  Herodatus, 
shortly  following  an  ei:)idemic  which  occured  in  430  n.  c,  and  its 
importance  has  been  i)articularly  emphasized  by  Oalcn  (164  A.  D.), 
who  pointed  out  the  clinical  manifestations  of  the  ailment.  Since 
then,  Aretieus,  Celsus,  Sennerteus,  Benivieni,  Cruveilhier,  Roki- 
tansky,  Virchow,  Woodward;  and  later,  Lambl,  Loesch,  Kartulis, 
Quincke,  Roos,  Musser,  Osier,  Stengel,  Stockton,  Harris,  Councilman, 
Latteur,  Ogata,  Shiga,  Russell,  Flexner,  Hiss,  Barker,  Duval,  Bassett, 
Vedder,  Musgrave,  Strong,  Hartmann,  Whitmore,  Craig,  Siler,  Kruse, 
Cant,  and  others  have  contributed  valuable  information  to  the  subject. 

Benivieni  (1506),  held  the  first  autopsy  on  a  patient  who  died  from 
dysentery,  but  prior  to  this  Galen  showed  that  the  disease  was  confined 
to  the  colon.  Sennerteus  (1584)  pointed  out  that  dysentery  might 
be  epidemic  or  sporadic,  and  characterized  by  frequent  bloody  stools 
and  abdominal  pain  consequent  upon  intestinal  ulceration. 

Early  in  the  present  century  Cruveilhier  and  Rokitansky  for  the 
first  time  described  dysenteric  changes  in  the  bowel,  and  their  findings 
were  exemplified  later  by  Virchow,  and  more  recently  by  a  number  of 
investigators  mentioned  in  the  text. 

At  present  we  are  fairly  familiar  with  the  pathologic  changes  com- 
mon to  the  disease  and  know  that  it  is  caused  by  Entamceba  histolytica. 

Historic  Data  of  AmebcB  and  Entamebce. — Amebae  were  discovered 
in  the  dejecta  of  a  patient  suffering  froin  diarrhea  more  than  fifty 
years  ago,  and  they  have  since  been  investigated  by  a  number  of 
the  world's  best  authorities,  and  yet  we  do  not  know  positively  how 
many  varieties  there  are  and  which  are  pathogenic  and  which  are  not. 

Lambl  (i860)  found  amebic  in  the  feces  of  a  child  who  suffered  from 
diarrhea,  accurately  described  the  organisms,  and  intimated  that 
possibly  they  were  an  etiologic  factor  in  the  bowel  disturbance.  Ten 
years  later  Lewis  (1870),  while  investigating  cholera,  observed  amebce 
which  morphologically  corresponded  to  Lambl's,  but  attributed  no 
etiologic  importance  to  them.  Loesch  (1875)  encountered  in  the 
dejecta  of  a  patient  afflicted  with  chronic  recurring  dysenter\'  active 
organisms  of  a  like  character  and  named  them  Amoeba  coli.  The  amebae 
were  observed  at  \arious  times  while  the  dysenteric  process  was  active, 
and  Loesch  considered  them  resj)onsible  for  the  disease,  and  to  demon- 
strate their  pathogenicity  he  injected  infected  feces  into  the  rectum  of 
a  dog  and  succeeded  in  producing  ulcerative  and  inflammatory  lesions 
of  the  mucosa,  the  discharges  from  which  contained  organisms  similar 
in  every  way  to  those  found  in  the  patient's  stool.  This  in\'estigator 
showed  conclusively  that  the  Amoeba  coli,  which  are  now  believed  to  be 
the  same  asSchaudinn's  EntauKX'ba  histol\-lica,  were  a  causati\-e  iactor 
in  amebic  dysentery. 

During  the  next  ten  years  numerous  in\estigators,  including  Leuck- 
art,    Perroncito,    Cunningham,    Koch,    Grassi,    Kartulis,    Xormand, 


324  ENTAMEBIC    COLITIS,    DIARRHEA    IX 

Blanchard,  Hlava,  and  others,  found  amebffi  either  in  the  dejecta  from 
the  normal  bowel  or  feces  of  patients  suffering  from  dysentery.  Grassi 
encountered  them  alike  in  both  healthy  and  abnormal  feces.  About 
this  time  the  pathogenicity  of  these  organisms  became  the  subject  of 
hot  debate  because  some  investigators  maintained  that  ameba  were 
the  inciting  factors  in  dysentery,  and  others  that  they  were  of  little 
if  any  importance  as  an  etiologic  factor  in  the  disease. 

Those  who  argued  against  the  amebse  being  causative  factors  in 
the  disturbance  offered  the  following  reasons  for  the  belief:  (a)  The 
organisms  were  often  found  in  the  dejecta  from  healthy  intestines 
(Cunningham,  Perroncito,  Grassi,  Massciutin,  etc.);  {b)  encysted 
ameba?  could  be  swallowed  without  causing  the  disease  (Calandruccio) ; 

(c)  the  injection  of  garden  mold  into  the  rectum  of  cats  excited  an 
active  colitis,  the  stools  from  which  contained  amebae  (Gasser) ;  and 

(d)  dysenteric  matter,  free  from  the  organisms,  when  injected  into 
the  intestines  of  man  and  animals,  produced  dysentery,  and  the  con- 
sequent discharges  contained  amebae  (Sorga). 

Kartulis  (1885-86)  succeeded  in  demonstrating  the  presence  of 
amebffi  in  the  dysenteric  stools  of  the  living  and  in  sections  made  from 
intestines  of  patients  who  died  from  the  disease,  but  met  with  little 
or  no  success  in  cultivating  them.  The  organisms  were  absent  in 
fecal  discharges  and  microscopically  examined  gut  in  a  large  number 
of  individuals  who  died  of  tuberculosis,  typhoid,  typhus  fever,  and 
bilharzia,  but  in  150  consecutive  autopsies,  performed  on  subjects 
who  had  suffered  from  the  characteristic  manifestations  of  Egyptian 
dysentery,  he  found  amebae  in  every  instance. 

These  and  other  findings  convinced  Kartulis  that  these  protozoan 
agents  were  the  undoubted  cause  of  the  disease,  and,  further,  that 
amebse  were  proportionately  much  more  numerous  in  malignant  than 
in  the  benign  type  of  dysentery,  and  that  frequently  there  is  a  direct 
etiologic  connection  between  amebic  dysentery'  and  abscess  of  the  liver. 

Hlava  (1887)  in  60  cases  confirmed  the  views  of  Kartulis  as  to  the 
pathogenicity  of  amebic  dysentery,  and  by  injecting  infected  feces 
into  the  rectums  of  animals  obtained  positive  results  in  2  out  of  17 
dogs  and  4  out  of  6  cats  experimented  upon. 

Osier  (1890)  was  the  pioneer  in  this  work  in  the  United  States. 
He  discovered  amebse  in  the  dejecta  of  a  patient  afflicted  with  chronic 
dysentery,  the  morphology  of  which  closely  resembled  the  organism 
described  by  Kartulis.  In  the  same  year,  and  in  quick  succession. 
Musser,  Stengel,  and  Dock  made  similar  discoveries. 

To  Councilman  and  Lafleur  belongs  the  credit  of  (a)  first  vividly 
■  describing  amebae;  (b)  pointing  out  the  character  of  pathologic  changes 
incited  by  them;  (c)  assembling  the  characteristic  manifestations  of 
infectious  dysentery;  {d)  calling  attention  to  the  points  of  differentia- 
tion between  catarrh  and  amebic  dysentery;  (e)  showing  that  patho- 
genic Amoeba  dysenteria  (Councilman  and  Lafleur),  now  regarded  as 
Amoeba  histolytica  (Schaudinn) ;  and  harmless  organisms,  probably 
Amoeba  coli,  designated  1)\-  Schaudinn  as  Entamceba  coU,  ma>'  l)e  en- 


HISTORIC    NOTE  325 

countered  in  the  same  case  or  in  different  indiNiouas;  and  (/)  demon- 
strating that  amebic  d>-sentery  could  be  produced  in  cats  by  injecting 
into  their  rectums  pus  containing  amelxe  taken  from  an  abscess  in  the 
li\  cr. 

Numerous  investigators,  incluchng  Quincke  and  Roos  (1893),  and 
Kruse  and  Pasquale  (1894),  confirmed  the  findings  of  Councilman  and 
Lafleur  in  the  main,  and  have  demonstrated  conclusively  that  there 
are  two  types  of  ameba',  one  pathogenic  and  the  other  non-pathogenic, 
and  that  amebic  dysentery  can  be  produced  by  injecting  feces  contain- 
ing the  pathogenic  variety  into  the  rectums  of  cats  or  dogs. 

Casagrandi  and  Barbagallo  (1897)  claim  to  have  isolated  several 
varieties  of  ameba%  but  do  not  consider  that  they  are  etiologic  factors 
in  dysentery.  These  investigators  maintain  that  there  is  a  marked 
difference  between  the  amebse  of  man  and  the  organisms  found  in 
fresh  water,  and  suggest  the  name  Entamoeba  hominis  for  amebae  of  the 
Amceha  coli  variety,  an  arrangement  not  altogether  satisfactory  because 
different  species  exist  in  the  same  group. 

Strong  and  Musgrave  (1900),  Harris  (1901),  Jtirgens  (1902), 
Musgrave  and  Clegg  (1904),  and  others  have  succeeded  in  demonstra- 
ting the  pathogenicity  of  amebse  in  dysentery  and  abscess  of  the  liver, 
and  Jiirgens  confirmed  the  findings  of  Councilman  and  Lafieur  as 
regards  the  presence  of  both  pathogenic  and  non-pathogenic  ameba? 
in  the  stools  of  individuals  suffering  from  dysentery. 

Schaudinn  (1903)  encountered  both  harmless  and  d i seasc- producing 
ameba\  The  former,  which  was  met  with  in  the  dejecta  of  both 
healthy  and  individuals  suffering  from  dysentery,  he  named  Entamoeba 
coli  (see  Figs.  50,  51,  53),  and  the  latter,  the  chief  etiologic  factor  in 
true  dysentery,  he  designated  Entamoeba  hystolytica  (see  Figs.  48,  49, 
52).  His  studies  indicate  that  the  morphology,  method  of  reproduc- 
tion, and  life-cycle  of  non-pathogenic  differs  wideh'  from  that  of 
pathogenic  entameba". 

To  demonstrate  that  EntamcebcB  coli  were  harmless  and  Entamcebae 
histolytica  were  the  cause  of  dysentery  he,  on  different  occasions, 
swallowed  both  varieties,  with  the  result  that  the  former  caused  no 
inconvenience,  while  the  latter  incited  inflammatory  and  ulcerati\e  in- 
testinal lesions.  Four  years  after  these  experiments  Schaudinn  was 
still  suffering  from  dysentery,  and  died  from  an  abscess  in  the  sig- 
moid flexure  which  was  thought  to  have  originated  from  the  infection. 

Craig  (1903),  Hartmann,  Jiirgens,  Kartulis,  and  most  investigators 
of  amebic  and  entamebic  chsentery  and  zoologists  have  confirmed  the 
position  taken  by  Schaudinn  and  eidopted  his  classification.  Musgrave 
and  Clegg,  while  agreeing  in  the  main  with  Schaudinn,  differ  with  him 
in  that  they  hold  that  all  amebse  or  entameba?  are  potentially  patho- 
genic, and  that  so  long  as  they  are  present  in  the  bowel  the  patient 
has  amebiasis. 

Viereck  (1906)  described  a  new  pathogenic  species  of  ameba  associ- 
ated with  dysentery  which  he  called  Entama'ba  tetragena,  and  Craig, 
Hartmann,  and  Prowazek  ha\-e  confirmed  his  findings. 


326  KXTAMEBIC    COLITIS.    DIARRHEA    IN 

Craig  (1906)  discovered  a  pathogenic  organism  possessing  both  a 
flagellate  and  ameboid  cycle  of  development,  to  which  the  name 
Paramceba  hominis  was  given. 

Prowazek  (1904)  isolated  the  Entamaba  buccal  is;  Castellani  (1905), 
the  Entama'ba  undidans;  Lesage  (1908),  the  Entamwba  tropicalis; 
Ganducheau  (1908),  the  Entamceba  phagocytoides ;  Elmassian  (1909), 
Entamoeba  minuta,  and  Koidzumi  (1909),  the  Entamoeba  nipponica, 
which  differ  in  their  morphology  and  life  cycle.  No  doubt  other 
varieties  of  entameba  have  or  will  be  discovered  which,  like  the 
above,  are  pathogenic  in  man  and  animals,  on  the  one  hand,  or,  on  the 
other,  harmless  when  encountered  independently  or  together. 

Etiology. — While  true  dysentery  is  a  specific  disease,  the  symptom- 
complex  of  the  affection,  frequent  bloody  movements,  abdominal  pain, 
and  tenesmus  resulting  from  other  causes,  are  frequently  mistaken, 
diagnosed,  and  treated  as  dysentery. 

Undoubtedly  the  chief  factor  in  dysentery  is  contaminated  li'ater 
used  for  drinking  and  cooking  purposes.  In  some  instances  the  water 
is  rendered  impure  through  the  emptying  of  sewage  into  the  stream, 
and  in  others  wells  and  springs  are  polluted  through  the  drainage  from 
stables,  privies,  and  unhealthy  ponds,  which  finds  its  way  into  them  by 
gravitation. 

Strong  (1902)  collected  numerous  amebie  from  water,  but  did  not 
prove  their  disease-producing  power;  but  jMusgra\"e  (1904)  induced 
dysentery  in  a  monkey  with  water  amebae,  but  failed  to  infect  cats  by 
the  injection  into  their  rectums  of  organisms  taken  from  the  monkey's 
feces. 

Recent  investigators  have  shown  that  water  containing  amebae 
is  not  harmful,  and  was  demonstrated  by  Brown,  who  examined  the 
water  of  ships  arriving  at  eastern  ports  following  long  tropical  voyages 
that  contained  amebae  in  large  numbers,  but  which  did  not  cause 
diarrhea  or  dysentery  among  the  crew  who  constantly  used  it.  In 
tropical  countries  rain-water  collected  in  tanks  usually  contains 
amebse  in  abundance,  but  they  are  not  harmful.  Turbid  is  no  more 
dangerous  than  clear  water,  because  either  may  harbor  encysted  or 
harmless  entamebae. 

The  opinion  prevails  among  the  public  that  filtering  of  water  with 
household  filters  protects  them  against  dysentery  and  other  infectious 
diseases,  but  Brown  insists  that  if  once  a  filter  becomes  infected  it  is 
always  a  perpetual  source  of  danger  until  sterilized,  which  is  often  dififi- 
cult  or  impossible,  consequently,  when  a  filter  is  employed  it  should 
be  used  to  clear  the  water  before  and  not  after  it  has  been  boiled. 

Fresh  vegetables  from  gardens  which  receive  drainage  from  neigh- 
boring toilets  and  pri\ies  and  those  which  have  been  fertilized  with 
diluted  human  fecal  matter,  as  is  sometimes  practised  by  Chinese  and 
other  gardeners,  have  been  known  to  cause  dysenteric  colitis  in  a 
number  of  instances.  Musgrave  and  Clegg  have  demonstrated  that 
five  or  six  washings  of  lettuce,  tomatoes,  cucumbers,  radishes,  etc., 
were  insufficient  to  remove  the  amebie  from  salads,  which  indicates  that 


ETIOLOGY  327 

these  organisms  frequently  gain  entrance  to  the  alimentary  tract  alive 
or  in  the  encysted  state  through  the  medium  of  uncooked  food. 

Formerly  it  was  thought  that  once  the  soil  had  been  polluted  with 
the  feces  of  dysenteric  patients  it  remained  so  for  years,  and  it  was  shown 
that  during  wars  the  disease  has  repeatedh'  broken  out  at  different 
times  when  soldiers  ha\'e  recamped  upon  infected  ground,  ihcnigh  years 
had  elapsed  since  the  preceding  epidemic  had  occurred.  Authorities 
now  agree  that  entamebic  dysentery  is  spread  b\-  Hies  and  individuals 
who  harbor  cntameba'. 

K.xposure  to  a  high  temperature,  sudden  change  from  a  hot  to  a 
colder  climate,  unh\-gienic  surroundings,  poor  and  infected  food,  dissi- 
pation, li\ing  in  low-King,  swami:)y  countries,  exhaustion,  debility  and 
malaria,  anemia,  ptomain-poisoning,  catarrhal  and  ulcerative  condi- 
tions of  the  intestine — one  and  all  pa\e  the  way  for  or  aggravate  dys- 
enter\-. 

Classes. — Dysentery  attacks  all  classes  alike,  but  is  most  common 
and  fatal  among  the  poor,  who  are  badly  nourished,  live  in  an  unhealth\- 
atmosphere,  follow  arduous  occupations,  or  constantly  expose  them- 
selves. 

Age. — Dysentery  is  most  frequently  encountered  in  persons  be- 
tween twenty  and  thirty-five  years,  although  it  may  occur  in  the  aged 
or  very  young  children,  as  was  shown  by  Amberg,^  whose  patients 
were  two  and  one-half,  three,  four,  and  fi\e  years  of  age,  and  there 
is  on  record  a  case  of  amebic  dysentery  which  occurred  in  a  breast-fed 
Chinese  baby.  Children  are  less  apt  to  become  infected  than  adults 
because  they  are  not  so  frequently  exposed  and  their  acid  (milk)  stools 
are  unfavorable  to  ameba?,  which  thrive  in  an  alkaline  media. 

Sex. — The  disease  is  much  more  common  among  men  than  women, 
since  they  are  more  frequently  exposed,  are  often  segregated  in  large 
numbers  while  working  on  railroads  or  in  mines,  etc.,  and  because  their 
duties  more  frequently  call  them  to  distant  countries  where  bacillary 
or  entamebic  colitis  is  endemic.  Of  the  200  cases  of  amebic  dysentery 
reported  by  Strong,  there  were  177  men  and  23  women,  and  this  author- 
ity avers  that  in  the  eastern  troi)ics  dv'sentery  occurs  in  the  ratio  of 
5  males  to  i  female. 

Racial  Predisposition. — In  this  country  it  appears  that  negroes  are 
less  apt  to  become  infected  than  whites,  for  Simon's  50  cases,  treated 
in  New  Orleans,  where  the  blacks  are  numerous,  included  42  white 
and  8  negro  patients.  While  Europeans  are  prone  to  amebiasis  and 
other  forms  of  dysenteric  colitis,  the  natives  (particularly  soldiers)  ol 
tropical  and  semitropical  countries  suffer  from  the  disease  \ery  much 
more  frequently,  because  they  live  in  the  midst  of  poor  hygienic  sur- 
roundings, are  careless  as  to  the  water  they  drink,  and  because  the\- 
often  eat  impure  and  indifferently  prepared  foods. 

Occupation. — Vocations  which  lead  to  exposure,  exhaustion,  and 
the  spending  of  time  in  districts  where  malaria  and  dysentery  are  com- 
mon render  the  subject  more  liable  to  the  disease,  but  otherwise  occu- 
'  Johns  Hopkins  Med.  Bull.,  1901,  p.  355. 


328  ENTAMEBIC    COLITIS,    DIARRHEA    IN 

pation  IS  unimportant  as  a  predisposing  cause  of  dysentery.  As  a 
matter  of  interest  it  may  be  stated  that  in  Simon's  series  of  cases 
there  were  25  laborers,  3  farmers,  4  merchants,  2  beggars,  and  a 
rabbi. 

It  has  been  said  that  dysenten,-  is  a  disease  of  war,  famine,  and 
exposure,  and  this  is  largely  true  because  the  disease  has  been  en- 
countered in  its  most  epidemic  and  malignant  forms  during  war  times 
in  different  countries,  but  it  has  proved  most  destructive  where  the 
fighting  has  taken  place  in  tropical  or  semitropical  countries,  as  will  be 
seen  by  a  glance  at  the  statistics  given  under  the  section  devoted  to 
the  distribution  of  the  disease. 

From  our  present  knowledge  of  the  causation  of  dysenteric  colitis 
it  would  appear  that  exhaustion,  overheating  from  long  marches,  in- 
sulihcient  and  improperly  cooked  food,  irregular  time  for  eating, 
sleeping  upon  the  damp  ground,  malarial  surroundings,  and  climatic 
and  atmospheric  conditions,  etc.,  play  no  part  in  the  actual  causation 
of  the  disease,  as  we  formerly  believed,  but  weaken  the  subject,  di- 
minish his  resistance,  and  render  him  unable  to  combat  Shiga's  and 
other  bacilli  or  entameba?,  the  specific  agents  of  dysentery'  (colitis), 
when  they  find  their  way  into  his  intestine. 

While  bacillary  and  entamebic  colitis  (dysentery)  is  prone  to  break 
out  during  war  and  often  causes  more  deaths  than  the  fighting,  it  has 
been  frequently  encountered  in  endemic  and  epidemic  form  in  asylums, 
prisons,  barracks,  and  other  places  where  people  are  assembled  in 
large  numbers  and  remain  anywhere  in  the  same  place  or  locality  for 
days,  weeks,  months,  or  years. 

The  disease  is  likely  to  break  out  among  such  assemblages  for 
severalreasons — viz.:  (a)  it  is  difficult  to  obtain  a  sufficient  amount  of 
pure  water  for  drinking  and  cooking  purposes;  {h)  toilet  facilities  are 
inadequate;  (c)  the  diet  differs  from  the  normal;  {d)  food  must  be  col- 
lected in  enormous  quantities,  and  it  is  difficult  or  impossible  to  pre- 
vent it  from  spoiling;  (e)  cooking  is  insufficient  or  bad;  (/)  their  manner 
of  living  subjects  to  exposure;  (g)  they  have  irregular  hours  for  eating 
and  sleeping ;  and  {h)  the  chances  are  that  one  or  more  of  the  assemblage 
are  diseased  or  act  as  carriers  for  the  specific  agents  of  dysentery. 

During  camp  life  the  probabilities  are,  in  the  majority  of  instances, 
that  dysentery  starts  through  infection  brought  about  by  flies  or 
contact  (usually  the  fingers),  and  not  through  contaminated  water, 
vegetables,  or  food. 

Jehle  and  Charlton  hold  that  bacillary  dysentery  is  generally  due 
to  the  eating  of  spoiled  foods,  but  this  Kruse  questions.  It  has  been 
demonstrated  that  certain  individuals  are  carriers  of  dysenteric  bacilli 
and  entamebae,  the  same  as  others  are  of  the  typhoid  bacillus,  and  that 
healthy  individuals  may  contract  the  disease  from  them  under  favor- 
able conditions. 

Craig  estimates  that  50  per  cent,  of  human  beings  harbor  amebae, 
but  this  signifies  nothing,  since  they  are  harmless. 

Pringle  holds  that  the  contagion  may  directly  pass  from  one  per- 


ETIOLOGY 


329 


son  to  another  in  the  same  tent  or  room,  and  from  them  to  others 
through  the  mecHum  of  rotten  straw,  clothing,  etc. 

Persons  afiliicled  with  dysenteric  coUtis  have  frequent  fluid  e\acua- 
tions,  and  often  the  feces  are  discharged  with  force  and  before  the 
patient  is  in  a  proper  position,  with  the  result  that  the  toilet  seat  be- 
comes soiled  and  infected,  and  it  is  not  unreasonable  to  suppose  that 
healthy  individuals  may  contract  the  disease  through  the  anus  or 
buttocks  coming  in  direct  contact  with  the  bacilli  or  ameba?  of  such 
deposits,  because  it  has  been  shown  that  these  organisms  retain  their 
pathogenicity  for  hours  or  longer  when  the  stools  remain  warm,  as 
would  be  the  case  in  temperate  or  tropical  climates.  It  has  also  been 
shown  that  an  ice-cold  temperature  renders  ameba?  temporarily  inact- 
ive, but  that  they  again  assume  their  pathogenicity  under  favorable 
conditions.  The  crossing  of  a  river  in  Africa  by  F"rench  soldiers  was 
immediately  followed  by  an  epidemic  of  dysentery,  and  it  was  formerly 
thought  that  the  infection  occurred  from  direct  contact  with  the  water 
or  food  which  was  contaminated  by  it,  but  thisview  has  been  discredited. 

In  camps  liies  are  an  important  factor  in  spreading  the  disease  by 
collecting  the  feces  upon  their  feet  and  legs  and  carrying  it  to  and 
infecting  the  water,  milk,  or  food  that  is  being  consumed  by  healthy 
individuals,  and  by  depositing  infective  material  upon  their  hands, 
mouths,  or  clothing.  Ameba;  and  probably  dysenteric  bacilli  like 
tubercle  bacilli  are  rendered  inactive,  but  are  not  destroyed  by  the 
gastric  juice,  and  when  introduced  into  the  body  with  water  or  food 
they  are  practically  harmless  until  they  have  found  a  lodging-place  at 
the  ileocecal  valve  or  in  the  appendix,  colon,  sigmoid,  or  rectum,  which 
they  infect  under  favorable  conditions  as  soon  as  their  vitality  has  been 
restored. 

The  author  agrees  with  Jelks,  in  that  the  infection  frequently  orig- 
inates in  the  lower  bowel  (often  upper  surface  of  the  rectal  valves),  from 
whence  the  disease  extends  upward  to  attack  the  colon  and  possibly 
the  ileum. 

Climatic  and  Seasonal  Prevalence. — Bacillary  and  entamebic 
dysentery  (colitis)  have  been  encountered  in  tropical,  semitropical, 
and  in  colder  climates,  but  the  former  is  more  prevalent  in  non-tropical 
countries,  because  dysenteric  bacilli  are  not  so  easily  afTected  by  varia- 
tions in  the  temperature  and  atmosphere,  while  the  warmth  and  moist- 
ure of  hot  climates  favor  the  development  of  and  pathogenicity  of 
entamebai. 

Brown  has  pointed  out  that  entamebic  dysentery  is  more  manifest 
during  the  cool  season,  but  says  that  this  is  due  more  to  an  accentuation 
of  the  s\'mptoms  and  tendency  to  relapse  than  it  is  to  augmented  infec- 
tion which  is  prone  to  occur  during  the  hot  and  wet  months.  Hea\y 
and  prolonged  rainfalls  favor  the  spread  of  dysentery;  this  was  shown 
following  the  great  Manila  flood  (1Q04),  when  the  disease  became  epi- 
demic. In  this  wa\'  organisms  which  have  collected  in  various  places 
are  washed  out  and  pass  into  wells  and  streams  to  pollute  the  water 
used  for  drinking  and  cooking  purposes. 


330  EXTAMEBIC    COLITIS,    DIARRHEA    IX 

Entamehic  dysentery  (colitis)  may  quickly  follow  the  entrance  of 
active  pathogenic  entameba  {Entamceba  histolytica)  into  the  intestine, 
or  the  disease  may  develop  considerably  later,  when  they  are  encysted, 
in  patients  who  are  debilitated,  suffer  from  some  other  intestinal 
affection,  or  conditions  arise  which  would  incite  them  to  become  active 
and  cause  the  dysenteric  symptom-complex,  diarrhea,  abdominal  pain, 
tenesmus,  blood,  mucus,  and  pus  in  the  stools. 

The  virulent  Shiga  and  less  virulent  bacilli  (Flexner's,  Strong's, 
Duval's,  Hiss',  and  Russell's)  appear  to  be  able  to  withstand  the 
elements  for  months  or  longer,  and  are  then  capable  of  setting  up  a 
bacillary  colitis  after  they  reach  the  bowel.  At  present  some  of  the 
leading  authorities  assume  the  existence  of  hosts  or  intermediary 
carriers,  as  in  typhoid  fever,  in  the  bacillary  colitis,  but  a  study  of 
the  statistics  indicate  that  in  most  instances  this  type  of  dysentery 
is  carried  to  the  intestine  by  water,  milk,  or  infected  food. 

Geographic  Distribution  of  Dysentery  (Entamebic  and  Bacillary 
Colitis). — Dysentery,  formerly  considered  a  disease  of  hot  or  semitrop- 
ical  countries,  has  in  recent  years  been  encountered  in  nearly  all  parts 
of  the  civilized  world  in  epidemic,  endemic,  and  sporadic  forms. 
Dysenteric  colitis  undoubtedly  occurs  with  greater  frequency  in  warm 
and  tropical  countries,  particularly  in  districts  which  are  damp,  poorly 
drained,  and  where  the  surroundings  are  unhygienic  and  the  inhab- 
itants are  more  poorly  nourished  than  elsewhere.  Consequently,  it 
is  prevalent  in  the  Southern  States,  Cuba,  the  Philippines,  Japan, 
China,  Mexico,  South  Africa,  India,  and  South  American  countries, 
but  it  has  been  met  with  in  northern  Germany,  Russia,  Greenland, 
and  in  the  States  above  Mason  and  Dixon's  line.  Helminthic,  balan- 
tidic,  coccidic,  and  other  types  of  infectious  colitis  are  also  common  in 
tropical  countries. 

Both  bacillary  and  entamebic  dysentery  (colitis)  have  been  frequently 
encountered  in  European  countries,  the  United  States,  and,  in  fact, 
nearly  the  world  over,  but  the  former  is  more  prevalent  in  Great 
Britain,  Germany,  Russia,  the  United  States,  and  Japan  than  the 
latter,  which  is  extremely  common  in  the  Philippines  and  Panama. 

Bacillary  colitis  (dysentery)  is  more  destructive  in  Japan  than  in 
any  other  country;  occurs  in  epidemic  form,  and  as  many  as  60,000 
cases  have  been  reported  within  a  year  traceable  to  bacilli  carriers, 
or,  as  Shiga  puts  it,  explosive  epidemics  brought  about  through  the 
pollution  of  water  by  dysenteric  dejecta. 

During  war  soldiers  are  frequent  sufferers,  and  many  of  them  die 
of  the  disease  (entamebic  or  bacillary  dysenter}-),  an  example  of  which 
is  to  be  found  in  the  statistics  of  Woodward,  who  collected  259,071 
cases  of  acute  and  28,451  of  chronic  dysentery  in  the  Federal  service 
during  our  Civil  War.  During  the  Boer  War,  from  October,  1899,  to 
September,  1900,  11,143  Englishmen  were  admitted  to  the  hospital 
suffering  from  dysentery,  of  which  number  546  died,  and  the  proportion 
of  soldiers  afflicted  with  the  disease  and  the  deaths  following  were  very 
much  greater  during  the  siege  of  Ladysmith  and  Mafeking. 


CULTURE    OF    EXTAMKB.E  33 1 

Striimpcl  states  that  30  per  cent,  of  all  deaths  occurring  in  the 
Anglo-Indian  Army  are  due  to  dysentery.  Shiga  estimates  the 
number  of  cases  reported  in  Japan  in  ten  years  (1890-1900)  as  875,000, 
of  which  no  less  than  231,000  were  fatal,  a  mortality  of  26  per  cent. 

Dysenteric  colitis  is  exceedingly  common  in  Hong  Kong,  Cochin- 
China,  East  Indies,  and  Sumatra,  due  largely  to  amebic  and  bacillary 
infection. 

In  the  n(jrthern  I'nited  States  epidemic  dysentery  rarely  occurs, 
but  is  encountered  in  the  endemic  and  sporadic  forms  quite  frequently 
in  the  South.  If  one  is  to  judge  by  published  cases,  the  disease  for- 
merly occurred  very  rarely  in  this  countn.-,  or  it  was  incorrectly  diag- 
nosed, but  today  it  is  met  with  (juite  often. 

Dysentery  (entamebic  and  bacillary j  is  often  brought  here  and 
widely  distributed  by  soldiers,  merchants,  and  others  who  come  from 
the  Philippines,  Panama,  etc.,  or  other  infected  districts.  The  disease 
is  endemic  in  certain  sections  of  the  Southern  States  and  in  some  asy- 
lums, penitentiaries,  and  other  public  institutions,  and  sporadic  cases 
of  both  bacillary  and  entamebic  dysentery  or  colitis  have  been  en- 
countered throughout  the  States. 

The  author  has  in  recent  years  treated  20  patients  afflicted  with 
dysentery  (12  amebic  and  8  bacillary)  who  never  had  been  out  r^t  the 
States,  or,  in  so  far  as  they  knew,  come  in  contact  with  individuals 
suffering  from  the  disease.  Of  this  number,  1 1  had  always  lived  in  the 
Eastern  States  (New  York,  New  Jersey,  New  Hampshire,  Connecticut, 
Ohio);  the  home  of  3  were  west  of  the  Mississippi  River  (Missouri, 
Kansas,  New  Mexico) ;  i  was  from  Iowa,  while  the  remainder  came 
from  Tennessee  (i),  Louisiana  (2),  Kentucky  (i),  and  Mississippi  (i). 
At  the  ratio  with  w'hich  bacillary  and  amebic  dysentery-  is  increasing, 
unless  radical  means  are  taken  to  prevent  its  spreading,  the  disease 
will  soon  be  classed  with  the  more  common  affections  of  the  gastro- 
intestinal tract. 

Culture  of  Entamebae. — Investigators  have  met  with  more  success 
in  cultivating  non- pathogenic  than  the  pathogenic  parasitic  ameb^e 
encountered  in  the  human  aHmentar\'  canal;  in  fact,  some  of  the 
most  reliable  authorities  in  this  work  maintain  that  the  latter  ha\e  not 
been  successfully  cultivated,  while  others  insist  that  they  have. 

Numerous  attempts  have  been  made  by  Craig  to  cultivate  the 
Entam(eba  histolytica,  E.  tetragena,  and  E.  coli  taken  from  the  stools 
of  patients  which  contained  them,  and  his  efforts  failed  in  ever\' 
instance. 

Free  non-pathogenic  ameb^e  usually  contaminate  the  water  and 
many  green  vegetables  in  all  parts  of  the  world.  It  is  probable  these 
organisms  have  been  cultivated  in  the  tropics,  though  attempts  in 
this  direction  have  failed  in  this  country. 

Musgrave  and  Clegg  admit  parasitic  entamebic  are  not  cultivable 
alone,  but  are  in  symbiosis  with  certain  bacteria.  Cats  inoculated 
with  such  cultures  remain  well,  but  monkeys  showed  dysenteroid 
symptoms  and  amebcc  in  the  stools. 


332  KNTAMEBIC    COLITIS,    DIARRHEA    IN 

Lesage  airried  a  growth  of  Entamcvba  histolytica  through  a  series 
of  66  subcultures  along  with  bacterium,  but  if  he  succeeded  in  pro- 
ducing dysentery  in  animals  with  the  cultures  he  does  not  mention 
the  fact. 

Xoe  succeeded  in  cultivating  eutamcbce  from  li\'er  abscesses,  water, 
and  dysenteric  stools  which  differed  in  some  but  resembled  Entamaba 
histolytica  in  most  respects,  and  Ganducheau  rendered  rabbits  immune 
to  amebic  infection  by  cultures  of  entameba  resembling  the  latter 
through  peritoneal  injections. 

Parasitic  amcbiv,  common  to  man,  grow  well  in  connection  with 
Bacillus  coli,  B.  typhosus,  B.  rubra,  B.  fluorescens.  Staphylococcus 
pyogenes,  and  vibrios  of  cholera. 

In  cultivating  ameb?e  derived  from  feces  Musgrave  and  Clegg 
proceed  as  follows:  "The  surface  of  the  special  culture-medium,  con- 
tained in  Petri  dishes,  is  smeared  with  a  culture  of  Bacillus  coli  or 
other  bacterium  with  which  amebae  grow  well,  and  the  feces  is  then 
smeared  in  concentric  circles  upon  the  surface  of  the  medium  or  in 
streaks  across  it.  The  plates  are  then  kept  at  room  temperature  and 
examined  upon  successive  days  for  at  least  a  week.  The  ameba?  can 
be  easily  seen  upon  the  plates,  as  they  wander  from  the  material  in  the 
spread  out  into  the  surrounding  medium,  and  the  course  that  they  take 
can  often  be  followed  by  the  development  of  colonies  of  the  bacteria, 
which  they  carry  with  them." 

Craig^  holds  that  the  entire  subject  of  the  cultivation  of  the  parasitic 
amebffi  is  in  a  chaotic  condition,  and  much  more  work  will  have  to  be 
done  before  it  can  be  accepted  that  any  of  the  parasitic  species  of  man 
have  been  cultivated,  and  believes  that  organisms  cultivable  on  arti- 
ficial media  are  free-living  and  not  the  parasitic  amebae  found  in  man. 

Walker,  who  has  given  considerable  attention  to  the  cultivation  of 
intestinal  ameba?,  maintains  that  (a)  parasitic  amebte  thrive  only  on  a 
solid  medium  and  one  which  is  neutral  or  alkaline;  (b)  that  bacteria 
are  essential  factors  in  their  cultivation,  and  (c)  that  they  multiply 
most  rapidly  in  the  presence  of  moisture,  free  oxygen,  and  a  tempera- 
ture of  from  20°  to  25°  C. 

Classification  of  Amebae  and  Entamebas. — Since  the  publication  of 
Craig's  work"  important  changes  ha\c  been  made  in  the  classification 
of  aniebcr  and  entamebcc,  largely  through  the  in\"estigations  of  Hart- 
mann,^  Whitmore,^  and  Calkins.^ 

Hartmann's  Classification: 
Order:  Amoebina  Ehrenberg. 
Genus:  Amoeba  Bory,  1822. 
Genus:  V'ahlkampfia  Chatton,  1912. 
Genus:  Entama'ba  Leidy,  1879,  em.  Schaudinn,  1903. 

'  The  Parasitic  Amcb;ie  of  Man.  iqii,  p.  66.  -  Ibid.,  1911. 

'  Kolle  u.  Wasscrmann's  Handbuch  d.  pathog.  Mikroorganismen,  vol.  vii;  Hartmann 
and  Whitmore,  .\rchiv.  f.  Protistenkunde,  24,  p.  182. 

^  .\rch.  Int.  Med.,  .\pril,  iqu,  vol.  ix,  p.  515;  Xew  York  Med.  Jour.,  .\ugust  9,  1913; 
The  Post-Graduate,  November,  loi.v 

^  Trans.  XV  International  Cong,  on  Hyg.  and  Demog.,  1913,  vol.  ii.  p.  2S7. 


CLASSIFICATION    OF    AMEB^    AND    ENTAMEB.E  333 

Definition  of  the  Order. — Organisms  which  during  their  entire  vege- 
tative Hfe  show  greatly  changing  form  and  move  by  so-called  pseudo- 
podia. 

These  peculiarities  are  brought  about  by  the  absence  of  inner  skele- 
tal elements  and  the  naked  surface.  Differentiation  into  ectoplasm 
and  entoplasm,  as  well  as  contractile  vacuoles,  are  not  present  in  all 
forms;  single  or  multiple  nuclei  (generally  true  car\'osome  nuclei)  are 
present;  reproduction  is  by  simple  into  two  or  multiple  divisions,  and 
hologamy,  merogamy,  and  autogamy  ha\e  been  mentioned  as  fertiliza- 
tion processes. 

Calkins'  Classification. — Calkin's  splits  up  the  old  genus  ameba  into 
allied  genera  as  follows: 

Ameba,  Craigia, 

Vahlkampfia,  Tremastigameba, 

Nagleria,  Entameba, 

Parameba. 

Points  of  Differentiation  Between  Hartmann  s  and  Calkins'  Classi- 
fication.— Organisms  which  ordinarily  grow  as  ameba',  but  which  under 
certain  outside  influences  become  flagellated,  are  considered  as  flagel- 
lata  by  Hartmann  and  as  amebae  by  Calkins.  The  flagellate  organiza- 
tion is  the  higher  in  Hartmann's  opinion,  and  this  flagellate  stage  is 
entirely  characteristic  for  the  particular  species,  the  flagellates  in  this 
stage  being  much  more  difterent  than  are  the  difterences  in  the  ameba 
state.  Therefore,  this  flagellate  stage  cannot  be  considered  as  an 
adaptation  to  fluid  media  or  any  such  change;  it  is  a  hereditary  charac- 
ter, and  is  gone  through  with  by  the  same  organism  under  the  same 
conditions,  always  in  the  same  way.  Many  of  the  undoubted  flagel- 
lates, as  Trichomonas  intestinalis,  frequently  appear  as  ameboid  or- 
ganisms in  the  stool,  but  their  position  as  flagellates  is  unquestioned; 
consequently,  these  ameboid  organisms  are  taken  out  of  the  group  of 
pure  amebse  and  grouped  with  flagellates  by  Hartmann — viz.,  Para- 
meba eilhardi  Schaudinn,  Parama^ba  hominis  Craig  (Cragia  hominis 
Calkins),  and  Trimastig-amoeba  philippinensis  Whitmore,  organisms, 
all  of  which  may  be  found  in  the  stool. 

Definition  of  the  Genus  Ameba. — Large  forms,  loo  ju  to  i  mm.,  hav- 
ing one  or  more  contractile  vacuoles  and  one  or  more  nuclei,  the 
nucleus  containing  a  large  caryosome  or  scattered  granules  of  chro- 
matin. 

Definition  of  the  Genus  Vahlkampfia. — Small  ameba?,  5  to  20  /x, 
which  move  by  a  single  pseudopcxl  pushed  out  at  the  side,  have  one  or 
more  contractile  vacuoles,  typic  nucleus  of  the  genus  and  a  large 
caryosome  with  variable  development  of  the  outer  nucleus  with  or 
without  a  nuclear  membrane.  The  nucleus  divides  by  promitosis  and 
the  cyst  contains  one  nucleus.  These  amebic  may  be  ectoparasites, 
semiparasites,  or  establish  themselves  as  parasites  for  a  time,  are 
commonh"  grown  from  feces,  water,  etc.,  may  be  confused  with  enta- 
mebic  on  that  account,  and  this  genus  has  caused  the  existing  confusion 
relative  to  the  cultivation  of  entameba?. 


334  ENTAMEBIC    COLITIS,    DIARRHEA    IX 


6 


% 


.^ 


^ 


Fig.  48. — Entamoeba  histolytica :  i .  \'egetative  form,  showing  the  cyclic  changes  in 
the  nucleus.  Above,  to  the  left,  is  a  hyaUne  pseudopod.  The  original  outline  of  the 
ameba  shows  at  a  slightly  higher  level.  2.  \"egetative  form,  showing  coh  tj'pe  of  nucleus. 
3.  \'egetative  form,  showing  spindle-shaped  carj-osome.  4.  Beginning  encystment.  5, 
Indi\"idual  with  large  vacuoles  in  the  cytoplasm,  and  indistinctly  staining  nucleus.  Prob- 
ably degenerating  form.  6.  Degenerating  form.  The  nucleus  has  lost  its  structure;  the 
chromatin  is  collected  in  masses  inside  the  nuclear  membrane.  Chromidia  in  the  cj-to- 
plasm.  7.  Beginning  encystment.  There  is  a  large  vacuole  in  the  cytoplasm.  The 
nucleus  is  poor  in  chromatin;  there  is  no  carj'osome.  and  there  is  a  thin  layer  of  fine  gran- 
ules of  chromatin  around  the  periphen,-  of  the  nucleus.  There  is  no  evidence  of  nuclear 
membrane.  8.  Beginning  encystment.  Large  vacuole  and  numerous  chromidia  in  the 
cytoplasm.  9.  Like  7,  but  there  is  no  vacuole  and  there  is  a  large  chromidium  in  the 
c\"toplasm.     10,  II.  Complete  cysts  with  four  nuclei.     fWhitmore.) 

.\11  figures  are  from  preparations  fLxed  with  sublimate-alcohol  and  stained  with 
Heidenhain's  or  Rosenbusch's  iron-hematoxylin. 

The  drawings  were  made  with  .\bbe's  camera  lucida,  with  the  drawing-table  at  the 
level  of  the  stage  of  the  microscope.  Zeiss  apochromatic  obj.  2  mm.,  Compens.  oc.  12, 
Magnification  about  1950. 


CLASSIFICATION    OF    AMIiB.E    AND    EXTAMFB.E  335 

Definition  of  the  Geyiiis  Entameba. — Amclxe,  20  to  100  }x.  The 
nucleus  is  characteristic,  there  is  a  small  caryosome,  well-developed 
outer  nucleus,  and  a  double-contoured  nuclear  membrane.  The 
caryosome  shows  c>  clic  changes,  the  cysts  are  polynuclear,  and  there 
is  generally  no  contractile  vacuole,  for  the  parasitic  amebcC  and  marine 
forms  do  not,  as  a  rule,  have  a  contractile  vacuole,  while  those  living 
in  fresh  water  do.  Fresh-water  ameba'  heiving  a  contractile  vacuole 
lose  it  when  jilaced  in  sea-water  and  regain  it  when  returned  to  fresh 
water. 

EntamebcC  (histolytica)  are  the  parasitic  amebie  and  usually 
spread  from  host  to  host  Ijy  cysts  (Fig.  48)  which  they  form. 

Craig's  classification^  included  several  entameiicC,  \\z.,  EntamcEba 
coli,  E.  histolytica,  E.  buccalis,  E.  tetragena,  E.  phagocytoides ,  E.  tropi- 
calis,  E.  minuta,  E.  nipponica,  E.  kartulisi,  E.  iindiilans,  E.  piilmonalis, 
E.  iirogenitalis,  E.  miurai,  E.  gingivalis,  E.  dentalis,  and  his  Parama'ba 
hominis,  but  recent  investigations  have  show^n  that  E.  histolytica 
causes  entamebic  colitis  (dysentery). 


'<¥)  -   ^ 


# 


Fig.  49. — Entamceba  histoh'tica  cj^sts:  A,  Complete  four-nucleated  cyst  with  chro- 
midia.  B.  SLx-nucleated  cyst.  Two  of  the  nuclei  are  large  (the  two  that  have  not 
yet  divided).  This  is  an  abnormality  similar  to  the  EntamcEba  coli  cysts_with  more 
than  eight  nuclei.     (Whitmore.) 

The  recent  investigations  of  Hartmann  and  Whitmore  indicate 
that  there  are  but  two  entamebse — Entamceba  coli  and  E.  histolytica— 
parasitic  in  man,  of  which  the  former  is  harmless  and  the  latter  patho- 
genic (Figs.  49,  50).  These  authorities  hold  that  entamebiasis  is  in- 
variably caused  by  Entamceba  histolytica,  and  that  having  been  seen 
in  a  different  light  by  other  investigators  various  names  had  been  given 
it — viz.,  Entamceba  tetragena,  E.  minuta,  E.  nipponica,  E.  tropicalis,  E. 
phagocytoides,  E.  undulans,  and  E.  kartulisi,  t\'pes  which  do  not  exist 
and  must  fall  from  the  classification. 

The  cyst  formation,  as  described  by  Schaudinn  and  confirmed  by 
Cragi,  falls,  while  that  given  for  Entamceba  tetragena  (four-nucleated 
cyst)  holds,  and  since  E.  tetragena  and  E.  histolytica  are  the  same,  the 
latter  name  is  retained  because  of  its  priority. 

Entama'ba  gingivalis,  E.  iirogenitalis,  and  E.  dentalis  are  doubtttil, 
and  E.  miurai  and  E.  piilmonalis  are  not  considered  valid  species,  while 
E.  buccalis  (harmless)  stands  as  given  by  Craig. 

Paramoeba  hominis  (Craig)  is  taken  out  of  the  Order  Amebina  and 
is  put  in  the  flagellate  Order  Chrysomonadina . 

iThe  Parasitic  .Amebic  of  Man,  1911. 


336 


ENTAMliBIC    COLITIS,    DIARRHIiA    IN 


^ 


Fie;.  50. — Entamoeba  coli:  i,  Cyst  with  thirteen  nuclei.  This  is  an  abnormality 
which  is  not  uncommon  in  Entamoeba  coli.  (Cysts  with  up  to  sixteen  nuclei.)  2.  Vege- 
tative form  with  two  nuclei,  both  nuclei  in  division.  3,  Beginning  of  multiple  di\usion. 
Cyst  with  large  vacuoles;  nucleus  earlj'  in  division.  4,  Cyst  with  large  vacuoles.  The 
nucleus  has  completed  the  first  division.  5,  Complete  cyst  with  eight  nuclei.  The  large 
chromidium  is  rather  unusual  in  the  complete  coli  cyst.     (W'hitmore.) 


Morphology  of  Amebae  and  Entamebae. — The  morphologic  charac- 
teristics of  parasitic  amebiie  and  entameba^  encountered  in  the  human 
intestine  are  understood  in  a  general  way,  but  our  knowledge  relative 


MOkriIOLOGV    OF    AMEB.-E    AND    ENTAMEB.-E  337 

to  the  peculiarities  of  the  cHlYerent  \-arieties  is  not  yet  sufficient  to  en- 
able one  to  closely  distinguish  between  them.  The  task  of  differenti- 
ating one  entameba  from  another  has  been  made  more  confusing  by 
the  varying  description  given  by  investigators  of  the  individual  types, 
and,  further,  because  of  the  many  kinds  of  non-pathogenic  free-living 
amebcC  which  gain  entrance  to  the  bowel,  appear  in  the  feces,  and  are 
often  mistaken  for  the  parasitic  organisms. 

Entamebie  are  of  variable  size  during  the  developmental  stages, 
are  continually  changing  their  shape  when  in  motion,  and  assume  an 
ovoid  or  spheric  form  when  at  rest. 

Some  authorities  (Schaudinn,  Craig,  etc.)  maintain  that  it  is  not 
difficult  to  differentiate  between  Entamoeba  coli  (Fig.  50)  and  E. 
histolytica  (Fig.  48),  while  others  (Musgrave,  Clegg,  Strong,  etc.)  hold 
that  the  reverse  is  true. 

In  the  following  summary  relative  to  the  significant  characteristics 
of  Entamoeba  coli  and  E.  histohtica  Park'  has  conciseh'  given  the  dis- 


tinctive features  of  parasitic  entameba'  in  man — \iz.:  (i)  E.  coli  is,  on 
the  whole,  smaller  than  E.  histolytica;  (2)  its  ectoplasm  is  so  small  in 
amount  and  so  slightly  differentiated  that  it  is  only  seen  when  the 
organism  puts  forth  pseudopods,  while  the  cortical  zone  of  E.  histo- 
lytica is  wider  and  is  distinctly  differentiated  from  the  entoplasm;  (3) 
the  pseudopods  of  the  former  are  small,  rounded,  delicate,  and  not  highh- 
refractixe,  those  of  the  latter  are  larger,  finger  shaped,  firmer,  and 
more  highly  refractive,  thus  indicating  the  power  of  the  organism  to 
penetrate  its  host's  tissues;  (4)  the  nucleus  of  E.  coli  is  very  distinct  in 
life  as  well  as  in  stained  spreads,  due  to  a  definite  membrane,  a  more 
distinct  kar\osome,  and  much  chromatin,  which  is  distributed  through- 
out the  nucleus  with  more  of  a  collection  about  the  peripher>-;  the 
nucleus  of  E.  histolytica,  on  the  other  hand,  is  seen  with  difficulty 
during  life,  and  stains  faintly,  owing  to  its  delicate  membrane,  its 
small  amount  of  chromatin,  and  small  karyosome,  the  chromatin  is 
'  Pathogenic  Bacteria  and  Protozoa,  1910,  pp.  534-539- 


338 


ENTAMEBIC    COLITIS,    DIARRHEA    IN 


collected  about  the  karyosome  and  the  periphery  of  the  nucleus; 
the  nucleus,  moreover,  is  much  more  variable  in  shape  in  the  active 
organism  than  is  that  of  E.  coli;  (5)  the  entoplasm  of  E.  coli  is  less 
granular  and  vacuolated  and  contains  fewer  red  blood-cells  than  that 
of  E.  histolytica,  which  sometimes  shows  immense  numbers  of  these 
blood-cells. 

Motility. — As  a  rule,  entamebai  are  constantly  on  the  move,  fre- 
quently change  their  form  and  arrangement  of  their  neoplasm,  but 
pathogenic  entameba?,  such  as  the  Entamoeba  histolytica,  are  actively 
motile  (Fig.  52),  while  non-pathogenic  E.  coli  are  very  sluggish  in 
their  movements — distinctions  valuable  from  a  diagnostic  standpoint. 

Locomotion  in  both  instances  is  effected  through  the  projection  of 
ectoplasmic  pseudopodial  extrusions  which  repeatedly  present  at 
different  points  on  the  circumference  of  the  organism.  The  pseudo- 
podia  of  Entamoeba  coli  are  grayish,  and  gradually  extend  as  the  ento- 
plasm flows  into  them  and  produces  a  slow  but  progressive  motion;  or, 
on  the  other  hand,  simultaneously  project  at  various  points,  which  in- 
duces motility  but  no  advance  of  the  organism. 


Fig.   52. — A  living   Entamoeba   histolytica   shown   in   three  successive  ameboid  stages 

(Hartmann). 

The  pseudopodia  of  Entamoeba  histolytica,  at  first  devoid  of  ento- 
plasm, are  more  clear,  refractile,  thick,  and  resistant  than  the  short 
and  rather  blunt  projection  of  the  E.  coli. 

According  to  Craig,  Entamoeba  histolytica  possess  three  forms  of 
motility:  (i)  active  progressive  motion;  (2)  the  extrusion  of  pseudo- 
podia without  progression;  and  (3)  movements  of  the  cytoplasm. 

In  both  species  of  entamebae  the  appearance  and  shape  of  the  pseu- 
dopodia vary  in  the  different  stages,  but  at  no  time  are  they  like 
those  of  the  free-living  or  non-parasitic  variety. 

The  motility  of  pathogenic  amebse  is  most  marked  at  the  bodily 
temperature,  and  their  activity  decreases  in  proportion  as  it  rises  or 
lowers,  a  peculiarity  which  enables  them  to  be  differentiated  from  the 
saprophytic  variety,  which  more  strongly  resist  heat  and  cold. 

All  entamebai  travel  faster  in  a  thin  than  a  dense  media,  but  E. 
histolytica  have  a  greater  driving  force  and  power  to  displace  objects 
blocking  their  course  than  E.  coli,  and  generally  progress  uninterrupt- 
edly in  a  definite  direction;  less  motile,  they  may  move  for  a  short 


REPRODUCTION  339 

disiance  one  way  and  then  turn  and  proceed  slowU-  in  another,  which 
enables  the  eye  to  follow  them  for  a  considerable  time. 

Duration  of  Life  and  Resistance. — Both  E.  coli  and  E.  histolytica 
ma\'  exist  in  the  alimentary  tract  for  weeks,  but  gradually  become 
less  acti\"e  outside  the  body,  even  in  the  presence  of  a  favorable  tem- 
perature, and  eventually  die,  though  the  latter  is  more  pugnacious 
than  the  former,  and  have  been  known  to  live  several  days,  and  when 
death  ensues  both  shrink  up  and  become  ovoid  in  shape.  Certain  of 
the  free-living  or  non-pathogenic  amebee  can  maintain  their  vitality 
at  higher  and  lower  temperatures  than  those  parasitic  in  man. 

Several  investigators  have  pointed  out  that  entamebaj  can  be 
destroyed  by  strong  electric  currents,  :v:-rays,  and  chemicals,  and  that 
they  respond  in  one  way  or  another  to  mechanic,  electric,  and  chemic 
stimulation. 

Park  has  pointed  out  that  while  pathogenic  entamebie  are  demotil- 
ized  they  may  still  be  infective  after  freezing,  and  Musgrave,  at  a 
suitable  temperature,  succeeded  in  keeping  an  encysted  culture  from 
d\"senteric  dejecta  for  a  month  and  a  half,  when  it  still  remained  viable. 

Reproduction. — But  little  has  been  added  to  our  knowledge  con- 
cerning the  reproduction  of  entameba?  (Figs.  50  and  53)  since  the 
publication  in  1903  of  Schaudinn's  investigations;^  the  exact  manner 
in  which  it  always  occurs  and  the  difTerent  varieties  is  not  positively 
known. 

There  are  four  methods  of  reproduction — simple  division,  schizog- 
ony, gemmation,  and  reproduction  within  a  cyst,  and  these  Craig  has 
described  as  follows: 

''Simple  Division. — This  method  of  reproduction  is  asexual  in 
nature,  and  consists  of  a  primary  division  of  the  nucleus,  which  may  be 
either  mitotic  or  amitotic  in  character,  followed  by  the  di\ision  of  the 
cytoplasm,  two  ameba?  being  thus  produced.  This  method  of  re- 
production occurs  in  all  species  of  amebffi  so  far  as  is  known. 

"Schizogony. — This  method  of  reproduction  is  also  asexual  in  nature, 
and  is  accomplished  by  the  division  of  the  kar\-osomc  by  primitixe 
mitosis,  after  which  the  nuclear  chromatin  becomes  collected  around 
ihe  nuclear  membrane,  while  the  cytoplasm  rids  itself  of  all  foreign 
material.  When  this  is  completed,  the  chromatin  divides  into  from 
four  to  eight  little  masses,  the  nuclear  membrane  ruptures,  and  the 
chromatin  masses  become  free  in  the  endoplasm.  Finally,  the  cyto- 
plasm divides  into  as  many  parts  as  there  are  chromatin  masses  and  a 
number  of  daughter  ameba?  are  thus  formed  (Fig.  53,  5). 

"Reproduction  Within  a  Cyst. — When  conditions  are  unfavorable 
for  the  vegetative  existence  of  ameba;  they  undergo  encystment  and 
reproduction  occurs  within  the  cysts.  The  method  of  reproduction 
within  a  cyst  varies  in  difTerent  species,  and  occurs  in  two  difTerent 
ways:  either  by  the  primitive  mitosis  of  the  nucleus,  followed  by  autog- 
amous fertilization,  or  by  the  nuclear  chromatin  becoming  dispersed 
throughout  the  cytoplasm,  followed  by  the  formation  of  minute  buds 
^Arbeiten  aus  dem  Kaiserlichen  Gesundheitsamte.  1903. 


340 


ENTAMEBIC    COLITIS,    DIARRHEA    IN 


containing  chromidia,  which  are  separated  trom  tne  parent  body  and 
form  spores  by  the  secretion  of  a  resisting  membrane.  In  this  condi- 
tion they  are  incapable  of  undergoing  further  development  until  sur- 
rounded by  conditions  favorable  to  vegetative  life.  These  methods 
of  reproduction  will  be  considered  more  fully  in  the  discussion  of 
individual  amebae." 

,, -Schizogony  ^^^ 


Fig.  S3- — Diagram  illustrating  the  life-cycle  of  Entamoeba  coli:  i,  Young  ameba; 
2,  adult  ameba;  2J.  reproduction  b\-  simple  di\-ision;  3,  the  dix-ision  of  the  chromatin  of 
the  nucleus  into  eight  groups  collected  upon  the  surface  of  the  nuclear  membrane;  4.  com- 
plete nuclear  di\-ision;  5.  schizogony,  or  di\-ision  of  the  ameba  into  eight  daughter  amebae; 
6,  commencement  of  cj-st  formation;  7.  primary'  di\"ision  of  the  nucleus  within  the  cyst; 
8,  incomplete  cell-di\-ision  and  formation  of  chromides;  o,  formation  by  the  chromides  of 
two  pairing  nuclei;  10.  formation  of  two  reduced  nuclei  by  each  pairing  nucleus;  11.  di\-i- 
sion  of  each  of  the  reduced  nuclei  into  a  free  nucleus  (male)  and  a  stationary-  nucleus 
(female);  12.  two  nuclear  stage  formed  by  the  merging  of  one  free  and  one  stationarv' 
nucleus;  13.  adult  cyst  containing  eight  daughter  nuclei  formed  by  the  repeated  di\ision 
of  the  new  nucleus;  14,  the  adult  cyst  after  reaching  the  intestine  of  the  host,  Uberating 
the  eight  amebae  formed  during  sporogonj-  (Hartmann). 


The  differentiating  points  between  the  different  species  of  entamebae 
as  regards  their  reproduction  are  too  varied  and  complex  for  discussion 
in  this  work,  and  because  of  this  the  reader  is  referred  to  the  pub- 
lished researches  of  Schaudinn  and  the  works  of  Craig,  Park,  and 
Brown,  where  thev  have  been  fullv  described. 


CHAPTER   XXIX 


ENTAMEBIC    COLITIS     ENT AMEBIASIS,    ENTAMEBIC    DYS- 
ENTERY,  DIARRHEA   IN    (Continued > 

PATHOLOGY   (INCLUDING  TROPICAL  LIVER   ABSCESS) 

The  changes  which  take  place  in  the  bowel  in  entamebic  cc^litis 
(dysentery)  vary  greatly  in  different  subjects,  because  in  some  in- 
stances the  disease  is  acute  and  in  others  chronic,  and,  further,  for  the 
reason  that  this  type  of  infection  is  excessively  virulent  in  one  indi- 
vidual and  less  so  in  another,  and,  finally,  owing  to  the  fact  that  enta- 
mebic colitis,  acute  and  chronic,  does  not  always  pursue  an  even  course, 
for  at  times  a  diphtheric-like  membrane  may  form  on  the  mucosa,  or 
the  superficial  tunics  of  the  bowel  may  become  extensively  involved 
through  a  mixed  infection  or  bx"  a  gangrenous  process  and  slough. 

Usually,  in  the  chronic  vari- 
ety, small  ulcers  form  and  the 
destructive  process  extends  by 
coalescence  until  large,  irregu- 
lar raw  areas  result,  and  the 
mucosa  becomes  undermined 
and  fistulous  intercommunica- 
tions form  which  connect  the 
ulcers. 

Some  idea  may  be  formed  as 
to  the  character  of  the  changes 
which  occur  in  the  mucosa  and 
the  bowel  during  life  by  in- 
specting the  lesions  through 
the  sigmoidoscope  and  examin- 
ing the  gut  at  autopsy,  but 
one  is  seldom  fortunate  enough 
to  secure  a  section  of  the  dis- 
eased intestine  for  inspection 
and    microscopic    examination 

while  the  dysenteric  process  is  active  (F"ig.  54);  consequently,  our 
knowledge  concerning  the  patholog\'  of  entamebic  colitis  is  not  com- 
plete, though  we  know  very  much  more  about  it  ihan  we  did  a  decade 
ago. 

Entamebic  has  been  occasionally  mistaken  for  bacillary  colitis,  but 
the  pathology-  of  these  forms  of  dysentery  is  so  distinctively  different 
that  physicians  familiar  with  them  will  not  make  this  error. 

Location  and  Distribution  of  the  Lesions. — Entamebic  colitis  is 
primarily  a  disease  of  the  colon,  though  in  rare  instances  the  specific 

341 


Fig.  54. — A  section  of  the  intestine,  show- 
ing Entamoeba  histoh-tica  within  the  mucous 
membrane;  X  750  (Craig). 


342  entami:bic  colitis,  diarrhea  in 

organisms  find  their  way  through  the  ileocecal  val\e  and  infect  the 
ileum.  It  is  possible  that  entamebic  ileitis  may  also  be  induced  by 
Entamoeba  histolytica,  E.  tetragena,  etc.,  which  gain  entrance  to  the 
intestine  through  the  drinking  of  infected  water  or  eating  of  contami- 
nated foods.  When  the  ileum  is  specifically  involved,  usually  not 
more  than  a  few  inches  or  at  most  2  feet  are  affected.  The  lesions 
here  and  the  manifestations  arising  from  them  resemble  so  closely  those 
of  the  colon  that  a  separate  description  of  the  pathologic  changes  and 
symptoms  of  entamebic  ileitis  is  considered  unnecessary. 

Clinicians  familar  with  the  disease  agree  that  the  cecum,  sigmoid, 
and  particularly  the  rectum  are  the  segments  of  the  colon  most  fre- 
qiienth'  and  severely  invoked  by  the  infective  process.  Usually  the 
trouble  originates  in  the  cecum  and  extends  downward,  but  the  author 

has  observed  cases  wherein  the 
focus  of  infection  was  primarily  in 
the  rectum  and  gradually  extended 
from  thence  upward  and  invoked 
the  different  segments  of  the  colon 
!^     and  cecum. 

^  Lesions  located  in  the  rectum 

are  usually  more  extensive  and  per- 
sistent than  those  in  the  colon, 
but  this  is  due  to  the  trauma  of 
the  parts  incident  to  defecation, 
prolonged  retention  of  toxic  feces 
in  contact  with  the  sores,  and  more 
^■T^j^m     -  o.  active  participation  01  streptococci. 

Fig.  55.-Entamebic  ulcers  of  the  sig-     colon    bacilli,    and    Other   obligate 
moid  flexure  and  rectum.  and    accidental    bacteria,    and    no 

good  reasons  have  been  advanced 
to  show  that  the  specific  organisms  (entameba?)  of  dysentery  are  in- 
dependently more  virulent  in  the  lower  than  the  upper  part  of  the 
large  bowel. 

In  catarrhal,  luetic,  tuliercular,  traumatic,  and,  in  fact,  all  forms  of 
colitis,  ulceration  is  most  marked  in  the  rectum  and  lower  sigmoid 
(Pig.  55),  and  here,  as  in  entamebic  and  bacillary  colitis,  the  lesions 
are  not  more  extensive  because  of  their  location  or  difference  in  the 
composition  of  the  rectal  mucosa,  but  to  the  constant  trauma  to  which 
they  are  subjected  plus  a  mixed  infection  participated  in  by  the 
pathogenic  and  pyogenic  bacteria  found  in  this  region. 

The  upper  conca\e  surfaces  of  the  rectal  valves  afford  an  excellent 
temporary  abiding  place  for  both  feces  and  entamebie,  and,  naturally, 
characteristic  ulcers  are  to  be  found  in  these  localities.  The  writer 
has  very  frequently  observed  lesions  in  their  varying  stages  here,  and 
Jelk,  a  close  student,  has  found  them  in  nearly  every  instance,  but  the 
lower  or  convex  surfaces  of  the  vakes  less  often  become  ulcerated 
than  the  rectal  wall. 

In  acute  entamebic  proctitis  the  mucosa  of  the  lower  rectum  is 


■..\J>:if  -*\-r.i  ^■^.-- 


LOCATION    AND    DISTKIHUTION    OF    THE    LESIONS 


343 


swollen,  edematous,  red,  sensitive,  and  occasionally  projects  slightly 
beyond  the  anal  margin  during  defecation  and  straining.  In  the 
chronic  form  the  membrane  of  the  anal  canal  is  less  angr>',  but  is 
irritated  owing  to  the  acrid  (Hschargc  which  is  constantly  poured  upon 
it  from  abo\  {'. 


Fig.  56. — Follicular  ukeraLiun  aiui   jjalches 
of  i)seudomembrane. 


Fig.  57. — FoUiiular  uli oration. 


Typic  d>'senteric  ulcers  haw  been  obserxed  b\-  the  writer  im- 
mediately above  the  anus  in  a  few  instances,  but,  as  a  rule,  character- 
istic lesions  were  not  found  to  a  great  extent  within  the  anal  canal, 
but  from  the  beginning  of  this  narrow,  tube-like  outlet  upward. 
The  ulcers  were  more  numerous  and  extensive  in  the  lower  jiart  of 

'  Army  Med.  Museum. 


344 


ENTAMEBIC    COLITIS,    DIARRHEA    IN 


the  true  rectum,  and  gradually  became  fewer  in  number  and  less  malig- 
nant the  further  up  the  examination  was  carried.  In  many  instances 
the  infection  seemed  to  be  confined  to  the  lower  bowel  or  sigmoid,  but 
not  infrequently  the  lesions  evidently  involved  all  or  a  large  part  of  the 
colon  (Figs.  56,  57).  Clinical  observation  and  autopsies  have  demon- 
strated that  widely  separated  segments  may  be  severally  involved  by 
the  infective  process,  while  intervening  portions  remain  unharmed,  and 
that  unobstructive  or  straight  pieces  of  gut,  like  the  ascending,  trans- 

\erse,  and  descending  colons,  are  af- 
fected less  often  and  severely  than  are 
the  cecum,  flexures,  and  rectum,  which 
Kmger  retain  or  make  passage  of  the 
feces  difficult. 

Brown  holds  that  the  entire  colon 
is  affected  in  60  per  cent,  of  all  fatal 
cases  of  entamebic  dysentery,  and 
that  under  such  circumstances  the 
lisease  is  most  malignant  in  the  rec- 
tum. Of  Craig's  78  cases,  57  showed 
lesions  in  the  cecum  and  rectum,  while 
the  intervening  gut  did  not,  and  the 
disease  extended  above  the  ileocecal 
\alve  in  but  two  instances. 

Except  in  the  terminal  gut,  where 
the  lesions  are  more  pronounced  ow- 
ing to  the  fecal  retention,  irritation 
incident  to  defecation,  and  more  ac- 
tive mixed  infection,  the  changes  con- 
sequent upon  entamebic  colitis  are 
about  the  same  in  all  parts  of  the 
colon  and  appendix. 

The     PATHOLOGY     of     entamebic 
colitis    or    dysentery    can    be    more 
clearly  and  consistently  studied  by  subdividing  the  disease  into  the 
(i)  acute  and  (2)  chronic  varieties. 

Acute  Entamebic  (Amebic)  Colitis. — Acute  entamebic  dysentery 
(Fig.  58)  may  be  mild  or  severe,  be  characterized  by  slight  or  grave 
changes  in  the  bowel,  and  in  one  instance  the  patient  may  succumb  to 
treatment  or  in  another  the  condition  may  become  subacute  and  event- 
ually terminate  in  the  chronic  form  of  the  disease.  In  favorable  cases 
infection  is  light  and  incites  a  catarrhal  colitis,  which  is  first  accompanied 
by  several  copious  fluid  evacuations  daily  containing  an  abundance  of 
mucus  and  a  slight  trace  of  blood,  abdominal  discomfort,  and  rectal  te- 
nesmus, and  later  by  a  persistent  diarrhea,  wherein  the  stools  are  smaller, 
with  marked  straining,  and  are  composed  exclusively  of  mucus  and 
blood  (pure  or  clotted).  In  the  presence  of  catarrhal  inflammation  the 
mucosa  is  congested,  has  an  intensely  red  color,  is  edematous,  streaked 

'  Army  i\led.  Museum. 


iS. — Acute 


jlonij  entamebiasis. 


ACUTE    ENTAMEIJIC    (aMEBIC)    COLITIS 


345 


with  blood,  smeared  over  with  a  glairy  mucus,  sensilixe  to  the  touch 
and  presents  hyperemic  ridge-like  folds,  and  the  submucosa  is  somewhat 
inflamed  and  thickened.  In  this  form  of  entamebic  ccjlitis  the  bowel 
lining  may  be  dotted  here  and  there  with  petechial  hemorrhages  or 
superficial  ovoid  ulcers,  which  respond  more  kindly  to  treatment 
than  classic  dysenteric  lesions.  In  some  instances  of  acute  entamebic 
colitis  the  infection  is  virulent  and  the  inflammation  very  active  and 
extensive,  in  which  case  the  absorption  of  toxin  is  so  rapid  that  death 
may  result  from  shock  before  the  stage  of  ulceration,  and,  as  Brown 
says,  on  opening  the  colon  the  mucosa  is  found  to  be  intensely  engorged 
and  swollen,  is  dark  blue  or  purple  in  color,  with  extensixe  arboriza- 


^X^O>^ 


Figs.  59,  60. — Entamebic  colitis  (dysentery).' 
Fig.  59. — Ulcerative  stage.  Fig.   60. — Appearance   of   pseudoincm- 

branous  (diphtheric)  colitis  before  it  be- 
gins to  slough. 

tions  of  congested  vessels,  and  numerous  extravasations  are  scattered 
over  the  surface.  There  is  seldom  any  ulceration  or  e\idence  of  deep 
suppuration,  but  points  of  superficial  necrosis,  many  of  them  already 
beginning  to  break  down,  are  abundant,  and  there  is  always  an  excess 
of  mucous  secretion,  and  here  and  there  patches  of  exudate  become 
closely  incorporated  with  the  disintegrating  mucosa  and  unite  with  it 
to  form  diphtheric  membranes  (Fig.  60).  In  the  more  acute  and 
fatal  (malignant)  forms  of  both  entamebic  and  baciUary  colitis  the 
highly  inflamed  intestine,  when  inspected  through  the  sigmoidoscope, 
presents  about  the  same  appearance,  but,  as  the  inflammation  sub- 
sides and  the  disease  becomes  subacute  or  chronic,  the  differences  in  the 
character  of  the  lesions  of  the  two  types  of  infection  are  apparent. 

'  Armv  ^led.  Museum. 


346  ENTAMEBIC    COLITIS,    DIARRHEA    IN 

So-called  acute  or  fulminating  dysentery,  inv'olving  the  mucosa 
(throughout  the  colon)  in  a  necrotic  process,  and  frequently  causing 
death  in  from  two  to  five  days,  is,  according  to  the  author's  belief,  of 
hacillary  origin  in  most  instances,  and  will  be  discussed  in  connection 
with  the  pathology  of  that  form  of  colitis. 

In  discussing  the  changes  which  occur  in  acute  entamebic  colitis 
nothing  has  been  said  concerning  the  manner  in  which  entameba? 
gain  entrance  into  the  mucosa  and  submucosa  and  cause  ulceration  be- 
cause the  subject  is  to  receive  full  consideration  below  in  the  section 
devoted  to  the  pathology  of  chronic  entamebic  colitis. 

The  appendix  very  often  becomes  infected  in  entamebic  and  bacil- 
lary  colitis,  and  treatment,  barring  appendicostomy,  frequently  fails 
because  the  nests  of  specific  organisms  can  neither  be  destroyed  nor 
dislodged,  and  remain  to  be  occasionally  discharged  into  and  reinfect 
the  colon,  sigmoid  flexure,  or  rectum  which  have  been  healed  by  irri- 


■(' 


w 


i 


♦, 


Fig.  6i. — Chronii    niiimchic   colitis.     Irregular   entamebic    (dysenteric)    ulcers  of  the 
colon.     Note  how  the  mucosa  is  undermined.^ 

gation  or  medical  treatment.  WooUey  and  Musgrave'-  estimate  that 
the  appendix  is  involved  in  15  out  of  every  200  cases  of  entamebic 
dysentery. 

Chronic  Entamebic  (Amebic)  Colitis. — Entamebic  colitis,  whether 
it  starts  as  an  acute  d\sentery  or  insidiously  and  without  producing 
the  usual  dysenteric  symptom-complex,  always  becomes  persistently 
chronic  when  it  is  permitted  to  go  untreated,  and  occasionally  so  in 
spite  of  all  remedies,  and  eventually  severely  injures  or  destroys  the 
colon  and  causes  chronic  invalidism  or  death.  In  some  instances  the 
disease  assumes  a  relapsing,  and  in  others  a  recurring,  form,  but  in  both 
the  intestinal  changes  are  very  similar,  though  in  one  case  the  infec- 
tion may  be  more  virulent  or  latent  than  in  another.  It  has  already 
been  intimated  that  the  structural  changes  in  hacillary  are  superficial 
and  concern  mainly  the  epithelial  layer  of  the  intestine,  while  entamebic 
colitis  is  a  deep-seated  aft'ection,  and  involves  the  submucosa  (first) 

1  Army  Med.  Museum. 

2  Reports  to  the  Bureau  of  Goverrunent  Laboratories,  Manila,  June,  1905. 


CHRONIC    i;XTAMKBIC    (aMEBIC)    COLITIS  347 

and  mucosa,  and  occasiondlU'  iUv  nuiscular  layers  (Fi^.  6i)  and  peri- 
toneal tunic.  The  former  type  of  inferlion  [)rogresses  inward  and  the 
latter  oiihvard  or  toward  the  intestinal  lumen. 

It  is  a  thoroughly  well-established  fact  that  the  Entamceha  coli, 
which  is  considered  harmless,  and  the  E.  histolytica,  of  the  pathogenic 
group  can  and  do  frecjuenlly  remain  free  in  the  intestine  for  a  short 
or  longer  time  without  inciting  colitis  or  causing  troul)le,  hut  when 
EntamocbcC  histohtica  find  their  way  into  the  submucosa,  multiply, 
and  generate  their  toxins,  they  soon  produce  the  lesions  and  manifes- 
tations commonly  associated  with  colitis  or  dysentery. 

There  has  been  considerable  controversy  as  to  the  manner  in  which 
these  organisms  find  their  way  through  the  mucous  membrane  into 
the  submucosa  and  exceptionally  into  the  intestinal  musculature. 
No  doubt  previous  catarrh  or  other  intestinal  disturbances  which  lead 
to  the  formation  of  diminutive  breaks,  erosions,  or  ulcers  in  the  epi- 
thelial lining  of  the  bowel  favor  this  process,  but  these  organisms,  under 
favorable  conditions,  also  possess  the  faculty  of  reaching  the  submucosa 
when  apparently  the  continuity  of  epithelial  covering  has  not  been 
disturbed.  Under  such  circumstances  they  collect  in  Lieberkiihn's 
follicles,  and  through  the  aid  of  their  pseudopodia  work  their  way 
through  the  walls  of  the  crypts,  the  leader  being  followed  by  other 
parasites  in  the  manner  practised  by  battleships  on  parade,  or,  accord- 
ing to  several  investigators  (Jurgens,  Schaudinn,  Dobter,  etc.),  enta- 
•mebse  penetrate  the  entire  mucosa,  finding  their  way  through  the 
interglandular  tissue.  Craig  suggests  that  the  organisms  secrete  a 
toxin  which  causes  the  initial  destruction  of  the  epithelial  cells  and 
paves  the  way  for  their  entrance  to  the  submucosa,  and  believes  that 
this  poison  also  participates  in  the  formation  of  the  gross  lesions  which 
follow.  The  examination  of  microscopic  sections  removed  from  the 
intestine  during  life  and  after  death,  both  in  the  pre-ulcerative  stage 
and  where  typic  ulcers  have  formed,  show  conclusively  that  in  this 
type  of  infection  entamebae  abound  in  the  submucosa,  and  here  inaugu- 
rate the  inflammatory  toxic  and  necrotic  processes  which  (assisted  by 
mixed  infection)  ultimately  lead  to  the  formation  of  the  characteristic 
lesions  observed  in  true  entamebic  colitis. 

The  writer  has  made  a  practice  of  grouping  the  lesions  and  mani- 
festations of  chronic  entamebic  colitis  into  three  stages — viz..  the 
pre-ulcerative,  ulcerative,  and  destructive — which  plan  will  be  followed 
in  discussing  the  pathology  of  the  affection. 

Pre-ulcerative  Stage. — When  conditions  favor  extension  of  the  in- 
fection, the  colony  of  entameba'  in  the  submucosa  is  constantly  being 
augmented  through  their  multiplication  by  schizogony  and  the-  fre- 
quent migration  to  the  region  of  additional  specific  organisms  from 
the  intestine.  As  a  result  of  this  acti\'ity,  distention,  generation  of 
toxins,  and  disturbance  to  the  circulation  evidences  of  infection  are 
soon  seen  in  the  overlying  mucous  membrane,  though  in  rare  instances 
and  in  some  inexplainable  way  the  destructive  process  subsides 
before  any  damage  has  been  done.     The  changes  which   take  place 


348  ENTAMEBIC    COLITIS,    DIARRHEA    IX 

in  the  mucosa  and  submucosa  following  entamebic  infection  are  sub- 
ject to  variation  accordingly  as  they  are  modified  by  the  virulence 
of  the  organisms,  general  health  of  the  patient,  local  disturbance  in 
the  bowel,  and  extent  to  which  ordinary  and  specific  bacteria  partici- 
pate in  the  infective  process.  The  disturbance  may  be  confined  to  a 
small  or  large  area  in  a  particular  segment  of  the  gut,  or  appear  almost 
simultaneously  throughout  the  colon  and.  possibly,  lower  ileum,  but 
usually  the  most  active  foci  are  to  be  found  in  the  rectum  or  sigmoid 
flexure. 

The  disease  early  manifests  itself  in  the  form  of  hyperemic  or  edem- 
atous spots  in  the  mucosa,  which  become  elevated  as  the  entamebic 
cellular  infiltration  and  secretions  in  the  submucosa  increase  and  forge 
outward.  These  diminutive,  ovoid  swellings  are  usually  located 
at  the  summit  of  the  folds  in  the  mucosa,  and  some  of  them  present  a 
hemorrhagic,  others  a  yellowish,  and  still  others  a  bright-red  appear- 
ance, and  in  the  affected  region  the  mucous  membrane  undergoes  a 
catarrhal  inflammation,  is  covered  with  a  glairy  mucus,  and  when  the 
papules  dotted  over  its  surface  are  incised  they  are  found  to  contain 
a  yellowish,  viscid,  sticky  fluid  composed  of  dead  cells,  mucus,  and 
entamebae.  In  time  the  epithelium  covering  the  nodulated  areas 
becomes  eroded  as  the  result  of  local  irritation,  generated  toxins, 
pressure  or  interference  with  the  circulation,  and  the  intestinal  feces 
and  bacteria  find  their  way  into  the  mucosa  and  submucosa,  where 
they  in  conjunction  with  entamebae  favor  the  rapid  production  of  the 
ulcerative  stage.  In  turn,  the  mucosa  at  the  summit  of  the  eleva- 
tions undergoes  necrosis,  and  yellowish,  round,  irregular-shaped  lesions 
form,  the  floors  of  which  are  composed  of  the  submucosa,  and  they  are 
smeared  over  with  a  gelatinous  secretion.  Brown  holds  that  in  char- 
acteristic cases  the  submucosa  becomes  inflamed  and  infiltrated  and 
the  connective-tissue  fibers  proliferate,  changes  which  lead  to  the 
formation  of  minute  buttons  of  adenoid  tissue  which  push  up  from 
below  and  appear  as  clusters  or  wart-like  buds  on  the  mucosa,  and  later 
that  the  central  portions  of  these  protuberances  separate  and  pus 
exudes  through  minute  openings  in  the  apices  of  these  mammillated 
growths,  which  are  usually  more  pronounced  in  the  sigmoid  flexure 
and  rectum.  In  either  case  the  initial  ulcers  are  raised  above  the 
level  of  the  healthy  bowel  and  the  mucosa  surrounding  them  is  red 
■  and  swollen. 

Ulcerative  Stage. — Following  the  formation  of  ulcers  the  destruc- 
tive process  extends  very  much  more  rapidly,  and  the  patient  begins 
to  complain  of  the  true  d\'senteric  symptom-complex — viz.,  diarrhea, 
mucus  and  blood  in  the  stools,  discomfort  in  the  lower  abdomen, 
and  rectal  tenesmus. 

Independent  of  the  fact  that  a  vent  has  been  formed  through  the 
mucosa,  entamebae  continue  active  in  the  submucosa,  which  becomes 
edematous  and  assumes  a  gelatinous  greenish-yellow  or  whitish  appear- 
ance, o\er  which  rests  the  inflamed  mucosa,  with  its  nodulated  swell- 
ings, and  punctate  or  larger  ulcers  encompassed  by  necrotic  tissue. 


CHRONIC    F:NTAMEBIC    (AMliHIc)    COLITIS 


349 


The  specific  orL,Mnisiiis,  aick'd  1)>'  other  i)aiho_u,c'nic  and  pyogenic 
bacteria,  their  toxins,  spheroichil  infiltration,  and  strani^uhition  of  the 
l)lood-vessels,  favor  extension  of  the  necrotic  process  dc^wnward  into 
the  muscular  tunic,  thru  in  the  suhmucosa,  and,  finally,  upward 
throui^h  the  muscularis,  mucosa,  and  mucous  membrane,  which  is 
e\idenced  by  papular  enlargement,  ecchymoses,  or  small  ulcerated 
patches,  with  the  healthy  mucous  membrane  and  arborization  of  the 
vessels  showing  between. 

In  long-standing  cases  the  lesions  are  abundant,  extensive,  and 
characteristic,  but  in  the  beginning  of  the  ulcerative  stage  of  enta- 
mebic  colitis  and  later  the  ulcers  vary  in  shape,  depth,  and  general 
appearance,  and  vary  from  a  few  confined  to  a  small  area  to  large 
munbers  scattered  over  considerable  segments  or  the  entire  colon. 

In  the  beginning  they  are  usually  superficial,  from  mustard-seed 
to  split-pea  size,  roimd  or  ovoid  in  shape,  have  congested,  thickened 


-r^ 


Fig.  62. — Entamebic  ulcers  of  the  colon:  <?,  Round  and  ovoid  (Harris'  ulcers);  h,  follicular.' 


edges,  a  punched-out  appearance,  are  of  a  gra\ish  or  \ellowisli  tint, 
and  are  most  commonly  situated  upon  the  summit  of  the  folds  in  the 
mucosa. 

Lesions  of  this  t\pe  are  frequently  designated  as  Harris'  ulcers 
(Fig.  62,  a  and  h),  since  he  was  the  first  to  describe  them. 

Sometimes  the  sores  are  linear,  follow  no  systematic  course,  and 
in  consequence  intersect  each  other  and  form  the  well-known  slellate 
ulcers.  Either  or  both  types  of  lesions  may  coalesce  to  form  elongated 
or  larger  and  more  irregular-shaped  ulcers  with  necrotic  edges,  the  bases 
of  which  are  congested,  covered  by  gelatinous  material,  and  formed 
by  the  submucosa  or  muscular  tunic.  These  and  the  more  serious 
lesions  which  form  later  show  a  tendency  to  follow  the  course  of  the 
blood-vessels  (or  form  at  a  right  angle  to  tlie  long  axis  of  the  bowel), 
but  not  to  the  degree  observed  in  tul)erculosis  of  the  intestine. 

Another  type  of  lesion  observed  fairly  often  by  the  author  in  enta- 
^  Army  Med.  Museum. 


350 


ENTAMEBIC    COLITIS,    DIARRHEA    IN 


mebic  colitis  is  the  so-called  collar-button  ulcer,  which  is  characterized 
by  a  good-sized  superficial  round  sore,  joined  to  a  much  larger  under- 
mined ulcer  (Fig.  63)  in  the  submucosa  by  a  narrow  neck-like  sinus, 
from  which  exudes  a  gummy  secretion  or  pus  which  keeps  the  mucosa 
constantly  irritated. 

In  some  cases  small  and  large  lesions  representing  the  diiTerent 
types  of  ulcers  are  present  at  the  same  time,  as  well  as  nodulated 
elevations  between  them,  which  later  become  necrotic  and  form  sores. 
Under  such  circumstances  it  is  easy  to  understand  how  the  ulcers  are 
extended  by  continuity  through  the  action  of  pathogenic  and  pyogenic 
bacteria  and  the  constant  formation  of  additional  infected  foci  con- 
sequent upon  the  multiplication  and  migration  of  entamebse  and  bac- 
teria, so  that  large  ulcers  or  enormous  raw 
areas  are  formed  in  the  colon,  sigmoid  flex- 
ure, or  rectum. 

Irrespective  of  the  characteristics  of  the 
lesions  in  the  beginning,  when  entamebic  coU- 
tis  is  fully  developed  classic  undermined  ulcers 
are  present  and  usually  dominate  the  destruc- 
tive process.  These  ulcers  are  at  first  small 
and  connect  with  much  larger  lesions  in  the 
submucosa.  but  later  attain  considerable  pro- 
portions superficially  and  by  undermining  the 
mucosa. 

Through  the  sigmoidoscope  typic  ulcers 
present  a  yellowish  tint,  reddened,  indurated, 
elevated,  uneven  and  undermined  edges,  and  a 
necrotic  or  irregular  bogg\'  floor  smeared  with 
pus  and  blood,  while  the  rims  and  floors  of 
older  and  partially  healed  ulcers  are  more 
rounded  and  smooth,  though  the  adjacent  mu- 
cosa is  undermined.  Usually  the  mucous  mem- 
brane and  muscular  coat  in  a  large  measure 
resist  the  infective  process,  which  often  destroys  the  submucosa  to  an 
extent  that  a  probe,  introduced  through  an  ulcer,  may  be  made  to  sweep 
around  and  beneath  the  mucous  membrane  from  one-half  to  several 
inches.  Exceptionally,  the  mucosa  and  musculature  suft'er  more 
extensively,  and  at  times  the  peritoneum  is  destroyed,  perforation 
occups,  and  the  patient  dies  from  peritonitis. 

When  entamebic  colitis  is  severe  the  serosa  is  usually  discolored 
and  thickened,  though  it  is  not  directly  involved  by  the  ulcera- 
tion. 

Typic  single  entamebic  ulcers  may  vary  from  i  to  4  inches  (2.5- 
10  cm.)  in  diameter,  but  when  they  coalesce  they  may  be  very  much 
larger  and  encircle  half  of  the  mucous  meml)rane  of  the  entire  circum- 
ference of  the  bowel.  Under  such  circumstances  the  mucosa  between 
the  raw  areas  may  remain  normal,  but  usualK-  it  is  inxolved  in  a  catar- 

^  Army  Med.  Museum. 


CHRONIC    EXTAMEBIC    (aMEBIC)    COLITIS  35 1 

rhal  inflammation  or  dotted  over  by  erosions  incident  to  the  irritating 
discharge  which  constantly  bathes  it. 

On  account  of  the  chronic  character  of  the  disease  exudates  de- 
posited in  the  submucosa  and  musculature,  induration  which  follows, 
and  density  of  the  peritoneum,  the  bowel  during  life  and  after  death 
presents  a  thickened  and  hardened  feel  when  rolled  between  the 
fingers,  and  when  inspected,  recent  ulcers  can  be  located  by  hyperemic 
spots,  and  older  or  partially  healed  lesions  by  contracted,  whitish 
areas  in  the  peritoneum. 

Destructive  Stage. — In  particularly  \irukni,  neglected  cases,  and  in 
those  where  the  patient's  general  health  or  complicating  local  disturb- 
ances aggravate  the  condition,  the  persistent  infectious  process 
inaugurated  by  Entamoeba  histolytica  and  augmented  by  the 
myriads  of  accidental  and  obligate  bacteria  in  the  bowel  frequently 
progresses  to  a  degree  which  seriously  incapacitates  or  destroys  the 
colon  and  induces  an  exhausting  diarrhea,  the  loss  of  considerable 
blood,  the  absorption  -of  pus  and  toxins,  marked  loss  in  weight,  and 
formation  of  liver  abscess  or  -disturbances  within  the  lung,  brain, 
spleen,  blood-vessels,  or  peritoneal  cavity  when  entameba?  reach 
them. 

When  the  patient  becomes  thus  sorely  afflicted  the  author  con- 
siders he  has  reached  the  destructive  stage,  and  will  rapidly  grow 
worse  and  die  if  proper  measures  are  not  promptly  taken  to  arrest 
the  disease. 

Naturally,  owing  to  the  lowered  resistance  of  the  patient  and  his 
inability  to  take  and  digest  nourishing  foods,  the  destructive  process 
now  progresses  rapidly,  large  areas  of  the  mucous  membrane  are 
destroyed,  the  submucosa  gives  way,  and  extensive  excavations 
form  beneath  the  mucous  membrane,  which  may  retain  their  in- 
dividuality or  communicate  with  a  number  of  other  cavities  by 
connecting  sinuses  (see  Fig.  61).  Pockets  that  ser\e  as  collecting 
places  for  infectious  material  may  lead  to  the  formation  of  ab- 
scesses and  fistuhe  from  which  thick,  yellow  pus  can  be  easily 
expressed. 

In  rare  instances,  owing  to  the  virulent  character  of  the  infection, 
peculiar  action  of  the  toxins  generated  by  the  specific  or  mixed  organ- 
isms, obstruction  to  the  circulation,  or  due  to  other  cause,  small  or 
extensive  areas  of  the  mucosa  become  gangrenous  and  slough,  exposing 
the  intestinal  musculature  (Fig.  64),  or  a  diphtheric  membrane  may 
form  and  cover  the  mucosa  of  the  rectum,  sigmoid  flexure,  or  colon 
(Fig.  65).  More  often,  however,  in  severe  cases  there  are  large  ulcers 
with  raised  edges  and  long,  trough-like  sores  in  the  intervening  mucosa, 
lesions  which  give  a  buffalo-skin-Uke  appearance  to  the  mucous  mem- 
brane, which  Craig  regards  as  fairly  common  and  characteristic  of 
entamebic  colitis. 

The  author  has  treated  two  patients  for  entamebic  colitis  who,  in 
addition  to  the  usual  lesions,  suffered  from  numerous  polyps,  which 
were  fragile,  varied  from  pea  to  olive  size,  and  were  scattered  ONer  the 


352 


EXTAMEBIC    COLITIS,    DIARRHEA    IX 


mucosa  of  the  rectum  and  sigmoid  flexure.    Some  showed  as  elevations, 
while  others  were  attached  by  pedicles  ^  inch  (1.25  cm.)  or  more  in 

length.  The  discharges  from  the 
bowel  in  these  cases  were  particu- 
larly oft'ensive. 

These  growths  (Fig.  67)  or  ex- 
crescences were  not  attributed  to 
the    entamebic    infection,     but     to 


Fig-  65. — Ulcers  and  sloughs  in  a  case  of 
acute  entamebic  dysenteric  colitis.* 


_  Fig.  64. — Entamebic  colitis  (dysen- 
teric) of  the  descending  colon  complicated 
by  gangrenous  sloughing  of  the  pseudo- 
membrane  (diphtheric)  and  mucosa.* 


Fig.      60.  —  l_  olonic      pseudomembranous 
patches  in  a  case  of  entamebic  colitis.' 


hypertrophic  changes  consequent  upon    prolonged   irritation   of   the 
mucosa  incident  to  the  acrid  discharge  which  bathed  it,  because  similar 

*  Arm}-  Med.  Museum. 


MICROSCOPIC    APPEARANCE    OF    ENTAMEBIC    ULCERS 


353 


cases  had  i)reviously  been  treated  by  him  which  were  undoubtedly 
due  to  othi-r  chronic,  inllaniniatory,  and  suppurative  diseases  of  the 
colon. 

Musgrave  maintains  that  sometimes  in 
neglected  cases  of  entamebic  colitis  a  catar- 
rhal condition  prevails,  the  intestine  atro- 
phies (enteritis  chronica  atrophicans),  the 
mucous  folds  disappear,  and  the  gut  be- 
comes thinner  and  longer. 

Microscopic  Appearance  of  Entamebic 
Ulcers. — The  l)owel,  when  sectioned  through 
an  ulcer,  reveals  the  elevated  character  of 
the  lesion,  the  surrounding  mucosa  con- 
gested, swollen,  edematous,  or  necrotic,  the 
blood-vessels  strangulated  through  pres- 
sure of  the  exudates,  spheric  cellular  infil- 
tration everxwhere,  lymph-channels  di- 
lated, thickened  and  misshaped,  and 
entamebct  in  large  numbers  in  the  ne- 
crotic edges  of  the  sores,  granulating  tissue, 
and  submucosa,  but  the  parasites  are 
encountered  in  greater  numbers  in  fresli 
and  round  than  in  the  old,  larger,  and 
more  irregular  lesions,  and  particularly  at 
points  undergoing  degenerative  changes. 

Entamebffi  may  be  encountered  in 
chains,  few  in  a  group  or  en  masse,  where 
they  are  accompanied  by  leukocytes  and 
other  evidences  of  inflammatory  activity, 
and  confined  to  the  regions  named  or  en- 
countered in  the  blood-  and  lymph-vessels. 

In  characteristic  instances  the  vascular 
and  lymphatic  systems  in  the  congested, 
infiltrated,  or  degenerating  submucosa  are 
enlarged,  thickened,  and  abnormally  ar- 
ranged, and  usually,  as  has  been  pointed 
out  by  Brown,  the  endothelium  is  shed, 
and  dense  thrombi,  formed  of  corpuscles, 
coagulated  lymph,  and  entamebic,  block 
the  lumen.  At  this  stage  of  the  morbid 
process,  however,  entamebcC  are  very  diffi- 
cult to  identify,  and  unless  the  preparation 
is  properly  stained  they  may  be  easily  con- 
fused with  endothelial  cells  or  other  mor- 
bid products.  The  closed  follicles  are  generally  inflamed  and  infil- 
trated, but  show  no  distincti\e  alteration,  and  only  in  exceptional 
instances  do  they  contain  en l amebic. 

'  Arnn'  Med.  Museum. 


I''ij;.  67.  — Pseu(.l(jpol\ix- 
complicating  entamebic  colitis 
(dysentery).' 


23 


354 


EXTAMEBIC    COLITIS,    DIARRHEA    IN 


The  presence  of  different  varieties  of  bacteria  encountered  in  the 
tissues  and  discharges  in  the  vicinity  of  entamebic  ulcers  demonstrates 
that  the  suppurative  and  necrotic  changes  are  the  result  of  mixed 
infection. 


"-i  ->v:s 


Fig.  68. — Peculiar  extensive  cli^lulli^.ll  ..i  lii 
chronic  entamebic  colitis. 


inimi>a  incident  to  cicatrices  in  a  case  of 
Note  healed  and  unhealed  ulcers.^ 


Healing  Tendencies  of  Entamebic  Ulcers. — Except  in  favorable 
or  properly  treated  cases  the  lesions  of  entamebic  colitis  exhibit  but 
a  slight  tendency  to  heal  because  they  obtain  but  little  rest,  owing  to 
the  accompanying  exaggerated  peristalsis,   irritation  caused  by  the 

1  Army  Med.  IMuscum. 


HEALING    TENDENCIES    OF    ENTAMEBIC    ULCERS  355 

feces,  and  the  furtherance  of  the  infection  by  entamebee  and  bacteria 
constantly  present  in  the  gut. 

When  the  bowel  is  drained  and  frecjuently  irrigated  with  anti- 
septic and  stimulating  solutions,  or  in  some  cases  under  internal  medi- 
cation, the  superficial  ulcers  clean  up,  become  covered  with  healthy 
granulations,  and  rapidly  heal,  while,  at  the  same  time,  the  exca\a- 
tions  beneath  the  mucosa  simultaneously  close  and  the  bowel  is  left 
practically  in  a  normal  condition,  except  that  the  destroyed  glands  are 
not  reproduced. 

Frequently,  owing  to  reinfection  and  other  causes,  the  almost  or 
entirely  healed  sores  often  completely  or  partially  break  down,  when 
the  patient  again  suffers  from  the  usual  manifestations  of  the  disease. 

Occasionally  healing  is  characterized  by  the  formation  of  a  thin 
or  thick  layer  of  scar-tissue,  which  contracts  and  puckers  the  adjacent 
mucosa  (Fig.  68),  or,  when  the  destruction  of  tissue  has  been  consid- 
erable and  involved  nearly  the  entire  circumference  of  the  gut,  par- 
tial or  complete  strictures  form. 


CHAPTER   XXX 

ENT AMEBIC    COLITIS    (ENT AMEBIASIS,    ENT AMEBIC    DYS- 
ENTERY), DIARRHEA   IN   {Continued) 

SYMPTOMS,  COMPLICATIONS 

Symptoms. — Usually  the  manifestations  of  entamebic  colitis  are 
fairly  characteristic,  but  in  some  instances  they  are  confusing  because 
of  their  close  resemblance  to  disturbances  consequent  upon  dietary 
indiscretion,  ptomain-poisoning,  enterocolitis,  and  inflammatory  and 
ulcerative  lesions  of  the  colon  of  tubercular,  bacillary,  luetic,  traumatic, 
or  gonorrheal  origin. 

The  symptoms  are  variable  in  different  people  and  stages  of  the 
disease,  and  one  person  may  remain  practically  well,  another  suffers 
moderately  from  abdominal  discomfort,  diarrhea,  pus,  and  blood  in 
the  stools,  while  another  soon  becomes  dangerously  ill  from  toxemia 
and  aggravated  dysenteric  manifestations.  Statistics  indicate  that 
the  disease  begins  acutely  in  from  50  to  60  per  cent,  of  the  cases. 

When  analyzing  the  symptoms  in  suspected  cases  of  entamebiasis 
it  is  well  to  remember  that  in  some  instances  patients  are  infected  by 
both  entamebse,  Shiga's,  Flexner's,  or  other  bacilli,  and  the  myriads 
of  pathogenic  and  pyogenic  micro-organisms  in  the  intestine  may  also 
actively  participate  in  the  disturbance  as  soon  as  the  mucosa  is  broken, 
and  the  sufferer  may  have  some  intercurrent  disease  which  may  modify 
the  symptoms. 

Entamebic  colitis  is  characterized  by  a  catarrhal  inflammation, 
ulcerative  processes,  a  diphtheric  membrane  formation,  or  the  super- 
ficial tunics  may  become  extensively  involved  in  a  gangrenous  process 
and  slough,  leaving  the  bowel  denuded  over  long  or  large  round  areas. 

Bacillary  less  often  becomes  chronic  than  entamebic  colitis,  and  the 
earlier  symptoms  of  the  former  are  usually  more  distressing  and 
dangerous  than  the  latter;  in  other  words,  in  the  average  case  bacillary 
is  most  dangerous  in  the  early  stages  and  entamebic  infection  in  the 
later  periods  of  the  disease.  Irrespective  of  whether  or  not  the  onset 
of  the  disease  is  mild,  moderately  severe,  or  dangerously  acute,  entamebic 
colitis  generally  becomes  chronic  and  greatly  debilitates  or  kills  the 
patient  after  months  or  years  of  suffering,  while  in  bacillar\^  colitis 
he  usually  recovers  or  succumbs  to  the  infection  within  a  few  days  or 
weeks,  and  relapses  complicate  the  former  more  often  than  the  latter. 

Latent  Types  of  Entamebic  Colitis  (Dysentery). — Ordinarily  this 

form  of  colitis  is  very  active  in  the  initial  stage  and  characterized  by 

the  dysenteric  symptom-complex — viz.,  diarrhea  with  blood  and  mucus 

in  the  stools,  abdominal  discomfort,  rectal  tenesmus,  etc. — but  less 

356 


CLASSIFICATION 


357 


often  (30  per  cent.,  Brown)  the  disease  makes  an  insidious  onset  and 
the  patient  suffers  from  anorexia,  minor  digestive  disorders,  lack  of 
desire  for  work  or  amusement,  and  possibly  constipation,  manifesta- 
tions which  would  not  lead  one  to  suspect  entamebic  infection  unless  he 
had  had  a  previous  experience  with  this  type  of  disease,  or  knew  that 
the  patient  came  from  a  country  where  dysentery  was  endemic.  The 
author  has  observed  cases  where  entameba?  abounded  in  the  dejecta, 
and  yet  there  were  few  lesions  in  the  rectum,  sigmoid,  or  colon,  and 
the  patients  did  not  complain  of  the  usual  dysenteric  symptoms;  and 
has  treated  patients  where  entameba'  were  present  in  the  stools,  the 
bowel  extensively  ulcerated,  smeared  with  mucus,  and  who  did  not 
suffer  from  diarrhea  and  bloody  stools  or  the  ordinary  signs  of  dysen- 
tery, but,  as  a  rule,  he  has  observed  that  dysenteric  manifestations 
appear  simultaneously  with  the  lesions  and  become  worse  propor- 
tionately as  the  ulcers  increase  in  size  and  number.  Other  patients 
have  been  studied  where  the  disease  became  acute  after  having  re- 
mained latent  for  weeks  or  months,  and  the  author  in  a  number  of 
instances  has  known  individuals  to  suddenly  develop  acute  symp- 
toms of  entamebic  colitis  who  had  been  previously  cured,  the  result 
ot  reinfection  from  contaminated  water,  food,  or  entameba^  which 
had  found  lodgment  in  the  appendix,  glands,  or  submucosa.  From 
what  has  been  said,  the  necessity  of  bearing  in  mind  that  the  infection 
may  have  been  latent  in  cases  simulating  entamebic  colitis  becomes 
(jbvious,  and  the  stools  should  be  examined  for  entamebie  whether  or 
not  the  patient  suffers  from  diarrhea. 

Necropsy  statistics  of  the  disease  show  conclusively  that  many 
persons  have  suffered  from  liver  abscesses  and  died  from  dysentery 
who  were  not  suspected  of  having  it,  owing  to  the  constipation  and 
other  symptoms  complained  of. 

Classification. — For  convenience  of  study  entamebic  dysenteric 
colitis  may  be  subdivided  into  three  types — viz.:  (i)  mild;  (2)  moder- 
ately severe;  and  (3)  aggravated,  any  and  all  of  which  varieties  may 
insensibly  pass  into  the  chronic  or  characteristic  form  of  the  disease. 

Mikl  Type. — In  this  variety  of  entamebic  colitis  the  affection  comes 
on  insidiously  and  the  health  of  the  patient  remains  fair,  though  he 
appreciates  that  there  is  some  intestinal  disturbance,  a  loss  of  appe- 
tite, and  suffers  slightly  from  diarrhea  unaccompanied  by  tenesmus, 
the  stools  showing  semisolid  or  fluid,  some  mucus,  and  but  little  blood. 
In  some  instances  he  suffers  from  alternating  diarrhea  and  constipa- 
tion, and  does  not  exhibit  the  typic  symptom-complex  of  dysentery 
for  weeks  or  months  (if  at  all),  l)ut,  as  a  rule,  the  manifestations  become 
fairly  characteristic  in  a  short  time. 

Moderately  Severe  Type. — This  type  of  entamebic  colitis  is  most 
common,  and  is  ushered  in  by  diarrhea,  abdominal  pain,  tenesmus, 
mucus  and  Ijlood  in  the  stools  in  varying  amounts  when  the  attack 
appears  abruptly,  and  the  patient  frecjuently  complains  of  chilly 
sensations,  nausea,  a  fever  wherein  the  temiierature  wirics  from  101°  to 
104°  F.,  and  a  slightly  increased  pulse.     The  evacuations  in  the  begin- 


358  ENTAMEBIC    COLITIS,    DIARRHEA    IX 

ning  contain  a  slight  amount  of  fecal  matter,  but  later  become  fre- 
quent and  fluid,  and  are  composed  chiefly  of  mucus  and  more  or  less 
blood,  and  their  passage  incites  an  aggravating  tenesmus,  and  there  is 
an  almost  incessant  desire  to  empty  the  bowel,  which,  when  accom- 
plished, affords  but  slight  if  any  relief.  The  acute  manifestations, 
when  toxemia  is  marked,  persist  for  two  or  three  days  or  longer,  and 
may  endanger  life  by  bringing  about  a  subnormal  temperature  and 
collapse  of  the  patient,  or  they  may  abate  and  he  will  suffer  from  the 
usual  dysenteric  symptom-complex  only.  When  the  disease  lasts 
for  a  considerable  time  there  may  be  intermissions  and  exacerbations 
of  the  chief  symptoms,  but,  except  in  the  latent  cases  referred  to, 
diarrhea  prevails,  though  the  stools  vary  greatly  in  number  and 
character.  In  moderately  severe  cases  with  an  acute  beginning  the 
evacuations  are  thin,  have  a  disagreeable  odor,  are  fairly  copious,  and 
vary  from  fi\e  to  ten  daily  for  the  first  few  days,  after  which  they 
become  smaller  and  may  either  diminish  or  increase  in  frequency. 
Often  the  patient  will  pass  from  ten  to  thirty  stools  in  twenty-four 
hours,  made  up  of  mucus,  blood  and  necrotic  tissue,  and  exception- 
ally a  fibrous  membrane.  In  the  beginning  and  later,  pressure  over 
the  colon  elicits  soreness  and  the  sufferer  complains  of  pain  in  the 
sigmoid  or  other  regions  and  of  vesical  and  rectal  tenesmus.  Ordi- 
narily there  is  very  little  gas  distention,  but  when  bleeding  is  profuse 
and  blood  is  retained,  and  when  ulcers  are  present  which  incite  entero- 
spasm,  gas  backs  up  and  causes  considerable  discomfort  or  se\'ere 
colicky  pains.  Untreated  and  improperly  treated  cases  of  entamebic 
colitis  gradually  or  rapidly  go  from  bad  to  worse,  and  the  patient  ex- 
hibits evidences  of  the  disease  in  many  ways — ^viz.,  loss  of  weight  (20 
to  30  pounds),  furred  tongue,  stomatitis,  inetiicient  digestion,  muddy  or 
sallow  complexion,  anorexia,  anemia,  profuse  perspiration,  headaches, 
melancholia,  muscular  weakness,  restlessness  and  disturbed  sleep, 
malnutrition,  weak,  slightly  accelerated  pulse,  exhausted  state  and  a 
high  (102°  to  104°  F.)  or  subnormal  temperature,  depending  upon  the 
degree  of  sepsis  incident  to  the  ulceration  and  mixed  (streptococcic) 
infection,  the  formation  of  a  liver  abscess,  or  perforation  and  perito- 
nitis. 

In  chronic  cases  diarrhea  is  frequently  intermittent  to  a  degree,  but, 
as  a  rule,  the  stools  are  more  uniform  than  at  the  onset  of  the  disease, 
and  undigested  remnants  are  to  be  seen  in  the  dejecta  along  with  the 
mucus,  blood,  tissue  debris,  and  pus  when  ulceration  is  marked  or  sub- 
mucous abscesses  have  formed.  In  the  average  case  the  movements 
are  multiform,  and  the  accompanying  tenesmus,  abdominal  discomfort, 
and  indigestion  are  so  distressing  that  the  patient  is  in  a  deplorable 
state  and  unable  to  obtain  rest  night  or  day. 

Aggravated  Type. — The  author  regards  as  aggravated  cases  of 
entamebic  colitis  wherein  the  patient  is  dangerously  ill  almost  from  the 
beginning  incident  to  the  generated  toxins,  extensive  involvement  in 
a.  diphtheric  or  gangrenous  process,  and  where  the  mucosa  and  some- 
times deeper  tunics  are  destroyed  over  large  areas  or  throughout  entire 


CLASSIFICATION'  359 

segments  of  the  colon.  Malignant  (hsentery  ma\'  be  severe  from  the 
onset,  develop  upon  the  basis  of  a  milder  type  of  infection,  or  in  sub- 
jects afflicted  with  local  bowel  disturbances  destroy  the  epithelium 
and  make  easy  the  entrance  of  entameba?,  other  micro-organisms, 
and  their  toxins  into  the  deeper  structures  and  blood-  and  lymj)h- 
vessels,  especially  in  individuals  in  a  run-down  conditicjn.  Where  the 
infection  is  virulent,  toxins  abound,  a  diphtheric  membrane  forms, 
or  the  inner  layer  of  the  bowel  becomes  gangrenous,  it  is  generally 
conceded  that,  in  addition  to  entameba?,  other  accidental  and  obligate 
micro-organisms  or  helminths  participate  acti\ely  in  the  infection, 
and  are  partially  responsible  for  the  severe  manifestations  and  exten- 
sive changes  which  take  place  in  the  gut. 

In  aggravated  cases  of  entamebic  colitis  the  patient  sometimes  com- 
plains of  malaise,  gastric  disturbances,  indigestion,  and  loss  of  appe- 
tite for  two  or  three  days  before  he  becomes  seriously  ill,  but,  as  a 
general  thing,  when  the  infection  is  virulent  the  sufferer  begins  to 
complain  almost  immediately  of  rigors,  followed  by  fever,  thirst,  occa- 
sionally nausea  and  vomiting,  severe  colic,  marked  colonic  pain  or 
tenderness  on  pressure,  and  diarrhea,  wherein  he  has  from  ten  to  fifty 
l^assages  in  twenty-four  hours,  the  first  of  which  are  slightly  feculent, 
contain  considerable  mucus,  and  may  or  may  not  show  traces  of  blood. 

As  a  result  of  the  absorbed  toxins  or  sepsis  which  ensues  the 
temperature  may  be  subnormal  or  rise  to  102°  to  104°  F.,  the  patient 
has  a  rapid,  feeble  pulse,  dry,  shiny  skin,  is  bathed  in  a  clammy  per- 
spiration, becomes  restless,  is  sometimes  delirious,  and  may  pass  into 
a  comatose  state  or  die  in  two  or  three  days  from  exhaustion  and  col- 
lapse, or  within  a  week  from  peritonitis  when  the  bowel  is  extensively 
injured  or  perforated  by  the  diphtheric  or  gangrenous  process,  but 
usually  the  urgent  symptoms  partially  subside  when  the  subject  passes 
the  danger-mark. 

In  diphtheric  and  gangrenous  entamebic  colitis  the  movements, 
which  run  from  thirty  to  forty  daily,  subsequently  diminish  to  half 
this  number  in  fatal  and  cases  which  become  chronic,  and  the  amount 
of  the  discharge,  which  at  first  is  copious,  gradually  diminishes,  until 
not  more  than  one  to  four  tablespoonfuls  is  encountered  at  a  sitting. 
The  stools  are  always  offensive  and  contain  little  blood  in  the  begin- 
ning, but  later  the  quantity  is  markedly  increased,  and  it  may  be  a 
bright  red  if  fresh,  or  a  dark  brown  color  when  it  has  been  retained; 
in  other  respects,  according  to  the  nature  of  the  case,  the  dejecta  is 
made  up  chielU-  of  mucus  containing  some  pus  and  mucofibrinoiis 
casts  of  the  bowel  in  the  presence  of  a  diphtheric  inflammation,  or 
necrotic  tissue  when  the  intestine  is  gangrenous. 

Abdominal  tenderness  remains  as  the  acuteness  of  the  attack  sub- 
sides, while  the  terrific  griping  pains  disappear,  but  the  burning  in 
the  lower  bowel  and  rectal  tenesmus  continue  to  make  the  patient 
uncomfortable  during  and  following  defecation. 

When  sloughing  has  been  extensive,  exhausting  diarrhea  and  the 
absorption  of  toxins  sometimes  may  continue,  with  the  result  that  the 


360  ENTAMEBIC    COLITIS,    DIARRHEA    IN 

patient  rapidly  loses  flesh,  strength  and  power  of  digestion,  and 
becomes  exhausted,  or,  where  the  destruction  of  tissue  is  less  extensive, 
acute  malignant  entamebiasis  may  insensibly  pass  into  the  chronic 
variety. 

Chronic  Entamebic  Colitis  (Dysentery). — From  what  has  been  said, 
it  may  be  inferred  that  the  mild,  moderately  severe,  and  aggravated 
types  of  acute  entamebic  dysenteric  colitis  may  one  and  all  subside 
into  the  chronic  variety,  which  constitutes  the  form  of  the  disease 
most  frequently  encountered  in  this  and  tropical  countries.  Persons 
afflicted  with  chronic  dysentery  complain  of  about  the  same  manifes- 
tations as  those  having  acute  entamebic  colitis,  but  they  are  less 
severe. 

Frequently,  in  long-standing  cases,  toxemia  and  tenesmus  are 
absent,  and  blood  and  shreds  of  tissue  disappear  from  the  stools, 
which  are  of  a  dull  yellow  color,  and  more  homogeneous  than  the  evac- 
uations of  acute  entamebic  dysentery. 

Patients  having  chronic  dysentery  may  go  along  for  weeks  or  months 
and  have  about  the  same  number  of  daily  evacuations  (three  to  ten), 
or,  as  the  result  of  dietary  indiscretions,  violent  exercise,  taking  cold, 
drinking  ice-cold  or  alcoholic  beverages,  or  without  apparent  cause, 
acute  exacerbations  may  arise,  and  while  they  last  the  evacuations 
increase  in  number,  the  dejecta  contain  a  greater  amount  of  mucus, 
blood,  and  pus  than  formerly,  and  the  patient  complains  bitterly  of 
abdominal  pain,  soreness  over  the  colon,  tenesmus,  and  a  constant 
desire  to  stool.  Occasionally,  in  latent  cases  between  acute  attacks, 
the  patient  may  suffer  from  constipation  or  costiveness  alternating 
with  diarrhea,  and  the  evacuations  often  contain  small  scybala  and 
are  influenced  by  the  character  of  food  consumed,  being  more  fluid  and 
frequent  (containing  undigested  food  remnants  under  a  mixed  diet) 
and  frothy  when  considerable  starch  enters  into  the  meal.  Some 
patients  hold  their  own  between  acute  exacerbations,  but  the  majority 
have  little  if  any  appetite,  digest  their  food  improperly,  are  septic  to 
a  greater  or  less  degree  incident  to  the  chronic  diarrhea,  and  become 
exhausted  and  greatly  emaciated,  are  afflicted  with  progressive  anemia 
and  have  a  glistening  parchment-like  skin,  sallow,  muddy  complexion, 
pigmented  face,  and  a  listless,  careworn  appearance.  When  toxemia 
is  extreme  the  patient  is  nervous,  has  melancholia,  feeble  pulse,  suffers 
from  malaise,  is  indifferent  to  social  and  business  affairs,  presents  a 
furred  tongue,  cracked  lips,  sordes,  weak  heart,  tympanites,  and  in 
fatal  cases.  Brown  says,  "small  quantities  of  loose  and  fetid  dejecta 
are  passed  involuntarily,  and  often  almost  continuously;  prostration 
greatly  increases,  and  after  a  short  period  of  unconsciousness  death 
results  from  paralysis  of  the  cardiac  muscle." 

Generally  in  acute  and  chronic  entamebic  colitis  the  movements 
have  an  alkaline  reaction  which  favors  the  multiplication  of  entameba?. 

Other  Symptoms. — In  afldition  to  the  manifestations  already 
mentioned  patients  afflicted  with  acute  and  chronic  entamebic  dysen- 
tery may  suffer  from  cyanosis,  heart  failure,  cerebral  emboli,  neuritis, 


METASTATIC    ABSCESSES  36 1 

chorea,  muscular  inco-ordination,  paraplegia,  inflammation  of  joints 
and  tendon  sheaths,  enlarged  lymph-nodes,  boils,  enterospasms,  skin 
affections,  thrombosis  of  the  portal  vein  or  colonic  mesentery,  intestinal 
perforation,  peritonitis,  adhesions,  angulations  and  thickening  or  stric- 
ture of  the  gut,  jaundice,  cholecystitis,  bronchitis,  hepatitis,  pleurisy, 
edema  of  feet  and  ankles,  albuminuria,  cancrum  oris,  stomatitis,  gastralgia, 
gastric  catarrh,  dyspepsia,  ptosis,  intussusception,  perityphlitis,  appendi- 
citis, pericolitis,  sigmoiditis,  proctitis,  hemorrhoids,  fistula,  fissure,  and 
small  or  large  abscesses  in  the  rectocolonic,  submucosa,  ischiorectal 
fossae,  brain,  liver,  lung,  spleen,  kidneys,  alveolar  and  buccal  tissues, 
psoas  muscles,  and  other  organs  or  over  the  entire  body  in  severe 
cases,  when  there  is  general  sepsis  and  changes  in  the  blood  and  urine. 

COMPLICATIONS 

Entamebic  appendicitis  frequeniK-  compWco-tes  entamebic  colitis ,  and 
the  same  can  Ije  ^aid  of  perit\phlitis.  and  in  such  cases  Entamoebce 
histolytica  are  frequently  demonstrable  in  the  appendicular  wall  or  dis- 
charge. Musgrave,  in  150  necropsies  (amebic  dysentery),  observed 
appendicular  lesions  in  14  cases,  in  6  of  which  the  infection  occurred 
from  the  cecum.  In  2  instances  the  author  failed  to  cure  entamebic 
colitis  owing  to  relapses  thought  to  be  due  to  reinfection  from  the 
appendix,  for  one  of  these  patients  was  later  cured  by  removing  the 
appendix,  and  the  other  by  using  it  as  an  irrigating  tube  (appendicos- 
tomy).  In  the  removed  appendix  entameba?  were  discovered  in  the 
contained  gelatinous  mucus  and  in  the  submucous  tissue.  Jelks  has 
called  attention  to  the  frequency  of  appendicitis  in  this  form  of  dysen- 
tery, and  others  have  reported  cases  wherein  the  appendix  was  involved 
in  a  catarrhal  inflammation,  ulcerated  or  perforated.  Perforation  is 
comparatively  rare  in  spite  of  the  fact  that  entamebic  ulcers  often 
involve  extensive  areas  of  the  gut  and  penetrate  deeply  into  its  struc- 
ture. In  119  cases  recorded  by  Musgrave  there  were  only  three  per- 
forations, one  of  which  occurred  early. 

Abscesses  and  Fistulse. — In  aggravated  chronic  cases  of  enta- 
mebic d\sentery  the  mucous  membrane  is  perforated  at  many  points 
with  ulcers  which  connect  with  diminutive  abscesses  beneath  the 
mucosa,  which  in  turn  communicate  with  others  through  numerous 
fistula?.  When  the  pus  fails  to  escape  and  collects  in  considerable 
amounts,  it  may  rupture  and  be  voided  by  way  of  the  bowel  or  form 
diverticula  or  pericolonic  abscesses.  In  the  rectum  perforation  occa- 
sionally occurs  and  the  pus  follows  the  bowel  downward,  and  perianal 
or  ischiorectal  abscesses  are  formed. 

Metastatic  abscesses  are  of  frequent  occurrence  in  the  liver,  less 
often  in  the  brain,  lungs,  spleen,  kidneys,  and  other  structures  far 
remote  from  the  original  source  of  infection,  and  occasionally,  in  the 
presence  of  marked  sepsis,  abscesses  become  generalized  or  the  patient 
suffers  from  furunculosis.  While  entamebae  are  at  times  found  in  these 
septic  foci,  the  probabilities  are  the  infection  is  mixed,  and  that  such 
abscesses   are   due  solely  or  in   part   to  streptococci,   staphylococci. 


362  ENTAMEBIC    COLITIS,    DIARRHEA    IN 

colon  bacilli,  or  others  of  the  pathogenic  and  pyogenic  intestinal  micro- 
organisms. Among  the  119  cases  observed  by  Musgrave,  22.6  per 
cent,  had  liver  abscesses,  9  of  which  ruptured  into  the  lungs. 

Hemorrhage. — Slight,  moderate,  or  profuse  bleeding  occurs  at 
one  time  or  another  in  practically  all  cases  of  entamebic  colitis.  Dan- 
gerous hemorrhages  are  rare,  and  may  be  the  result  of  the  encroach- 
ment of  a  small  ulcer  upon  a  large  vessel  or  extensive  sloughing 
and  injury  to  a  number  of  arteries  and  veins,  and  it  has  been  shown 
by  Strong  that  bleeding  often  occurs  coincident  with  hepatic  abscess 
and  that  the  coagulability  of  the  blood  is  markedly  below  par.  The 
bleeding  may  be  caused  by  a  dysenteric  or  mixed  infection,  ulcer,  or 
thrombosis  of  the  vessel.  A  hemorrhage  from  the  colon  is  indicated 
by  dark-brown  or  coffee-ground  evacuations,  and  that  of  the  rectum 
by  a  small  or  large  amount  of  bright  red  blood  in  the  movements. 

Skin  Afifections. — During  the  acute  stage  of  the  disease  the  skin  is 
dry  and  glistens,  but  within  forty-eight  hours  it  softens  and  the  patient 
perspires  freely.  In  the  chronic  form  of  the  disease,  particularly  in 
the  presence  of  extensive  intestinal  ulceration  and  marked  toxemia, 
the  integument  is  loose,  has  a  disagreeable  odor,  assumes  a  sallow, 
jaundiced,  or  muddy,  scrawny  appearance,  and  Jelks  has  observed  the 
skin  to  become  edematous  or  involved  by  an  erythematous  papular  or 
pustular  eruption,  and  investigators,  including  the  author,  have  known 
localized  or  general  furunculosis  and  urticaria  to  complicate  chronic 
entamebic  colitis. 

Perforation. — Since  in  entamebic  colitis  the  destruction  of  tissue 
is  confined  chiefly  to  the  submucosa,  perforation  is  rare,  and  occurs 
when  ulcers  assume  a  penetrating  character  and  when  the  bowel  is 
distended.  Where  leakage  takes  place,  general  peritonitis  usually 
ensues  and  the  patient  dies  quickly,  but  in  favorable  cases  an  abscess 
may  form  or  the  infected  material  may  become  blocked  in  by  localized 
adhesions.  Perforation  occurred  in  but  85  of  the  580  cases  recorded 
by  Beranger  and  Feraud. 

Stenosis,  Adhesions,  and  Angulations. — The  sequelce  of  acute 
entamebiasis,  in  so  far  as  they  relate  to  the  intestine,  are  not  numerous 
or  annoying,  but  they  are  common  and  seriously  impair  the  function- 
ating power  of  the  bowel  where  the  disease  is  chronic,  inflammation  is 
marked,  ulcers  are  numerous  and  large,  and  when  extensive  sloughing 
of  the  gut  takes  place.  Under  such  circumstances  the  colon  becomes 
thick  and  hard  and  is  often  made  tortuous  through  contracting  ad- 
hesions, which  form  and  draw  it  to  adjacent  structures,  causing  angula- 
tion. Strictures  (single  or  multiple)  of  the  colon  and,  more  particularly, 
the  rectum  are  quite  common,  and  are  induced  by  the  contracting, 
cicatricial  tissue  of  healed  ulcers  and  sloughs.  Occlusions  thus  formed 
may  be  annular  or  tubular  and  cause  partial  or  complete  obstruction, 
with  its  usual  train  of  symptoms.  Occasionally  intestinal  atrophy  is 
a  complication  of  entamebic  colitis,  and  sometimes  an  extensively 
ulcerated  bowel  heals  and  exhibits  little  or  no  evidence  of  the  disease, 
but  in  most   instances  the  bowel  is  left  deformed  or  its  function    is 


RECTAL    COMPLICATION'S  363 

impaired  to  such  an  extent  that  the  patient  suffers  to  a  greater  or  less 
degree  from  incHgestion,  constipation,  or  diarrhea  following  his  re- 
covery. 

Gastro-intestinal  Disturbances. — The  appetite  is  good  in  latent 
and  poor  in  active  entamebic  infections,  and  the  stomach  and  intestine 
are  usually  involved  in  ei  catarrhal  inflammation,  but  the  mucosa  may 
remain  unbroken  or  become  ulcerated.  Nausea  and  vomiting  occa- 
sionally complicate  acute  but  rarel>-  occur  in  chronic  entamebic  colitis, 
and  gastritis,  gastralgia,  dyspepsia,  hyperacidity,  achylia  gastrica, 
epigastric  pain,  and  gas  fermentations  are  more  or  less  frequent  com- 
plications. 

The  small  intestine,  barring  catarrh,  usually  remains  healthy,  with 
the  exception  of  a  lew  inches  of  the  lower  ileum  which  occasionally  be- 
comes infected  from  the  cecum,  when  the  ileocecal  valve  is  relaxed. 

Urinary  Changes. — The  amount  of  urine  voided  is  less  when  diar- 
rhea is  active,  and  normal  or  increased  between  the  attacks.  The 
specific  gravity  is  changeable,  but,  as  a  rule,  urinary  reaction  remains 
acid  in  all  stages  of  entamebic  colitis,  while  chlorids  which  diminish 
during  the  exacerbations  become  normal  during  the  quiescent  stage. 
Albumin  may  appear  temporarily  in  some  instances,  and  in  rare  cases 
where  the  kidneys  are  involved  remain  permanently. 

Blood  Changes. — The  alteration  in  the  proportion  of  the  red  cells, 
hemoglobin,  white  cells,  eosinophils,  and  other  constituents  of  the 
blood  are  modified,  but  not  to  an  alarming  degree,  in  acute  entamebic 
colitis,  but  in  the  chronic  form,  anemia,  which  is  a  constant  and  serious 
symptom,  results  from  the  loss  of  blood  where  the  intestinal  vessels 
have  been  injured  by  ulcers  and  changes  occur  in  the  component  parts 
•of  the  blood  incident  to  toxemia  and  sepsis  which  complicate  the  dis- 
ease. The  color-index  is  low  and  the  hemoglobin  is  materially  dimin- 
ished (about  35  per  cent.). 

In  a  series  of  twelve  blood-counts  made  by  Brown,  in  cases  of 
moderate  severity  in  which  the  average  duration  of  the  infection  was 
three  years,  the  results  were  as  follows: 

Red  blood-coqiuscles 1,850.000  to  3,240,000 

Leukocytes 10,500  to       12,000 

Hemoslobin 65  per  cent. 

Polymoqjhonuclears 60  to  65  per  cent. 

Large  mononuclears  and  transitional  forms 10  to  17  per  cent. 

Lymphocytes 20  to  25  per  cent. 

Eosinophils 5  to    6  per  cent. 

Mast-cells 4  per  cent. 

with  a  few  myelocytes,  normoblasts,  and  megaloblasts  in  some  cases. 
Rectal  complications  frequently  accompany  or  follow  entamebic 
colitis.  TluTi'  is  alwa\s  more  or  less  proctitis,  frequently  ./i^.^/^rcv  and 
erosions  induced  by  the  irritating  discharge,  internal  \enous  and 
■external  thrombotic  hemorrhoids  consequent  upon  the  diarrhea  and 
straining,  and  redness  or  ulceration  of  the  perianal  skin  caused  by  the 
discharge  and  frecjuent  wiping  of  the  anus  are  occasionally  encountered. 


364  ENTAMEBIC    COLITIS,    DIARRHEA    IN 

Submucous,  perirectal,  and  ischiorectal  abscesses  and  fistidcE  are 
common,  and  follow  an  infection  where  septic  material  becomes 
lodged  beneath  the  mucosa,  edge  of  an  ulcer,  or  is  carried  to  the 
part  through  the  circulation.  Adenomata,  papillomata,  and  swellings 
of  the  mucosa  are  fairly  common  and  are  due  more  to  trauma  and 
bathing  of  the  bowel  with  the  irritating  discharge  than  to  the  infec- 
tion. 

Hypertrophy  of  or  contraction  of  the  rectal  valves  results  from  the 
prolonged  inflammation  or  contraction  of  cicatrized  ulcers.  Now  and 
then  cryptitis  and  hypertrophy  of  the  anal  papillcs  are  induced  by  the 
prolonged  irritation. 

Rectal  ulcers  and  strictures  the  result  of  entamebic  colitis  have 
alrea(l\"  l)ecn  discussed. 

The  sphincter  muscle  in  dysenteric  cases  may  be  excited  to  spasmodic 
contraction  by  anal  ulcers,  or  it  may  become  fatigued  and  remain  in  a 
relaxed  state  and  permit  the  feces  to  involuntarily  escape,  when  the 
patient  suffers  from  continuous  diarrhea  and  frequent  evacuations. 

HEPATIC  ENTAMEBIC  (TROPICAL)  ABSCESS 

Liver  or  so-called  tropical  abscess  constitutes  the  most  common 
and  distressing  complication  of  entamebic  colitis,  and  results  from  a 
suppurative  inflammation  in  the  liver  incited  by  the  entamebae, 
which  gain  entrance  to  the  liver  through  the  portal  vein  or  in  ways 
described  below.  It  has  been  conclusively  shown  that  hard  drinkers 
afflicted  with  dysentery  sufi^er  much  more  frequently  from  hepatic 
abscess  than  abstainers.  The  following  statistics  indicate  that  the 
percentage  of  liver  abscesses  in  patients  afflicted  with  entamebic 
colitis  varies  greatly,  probably  owing  to  the  occupation  and  habits  of 
the  individual,  exposure,  virulence  of  the  infection,  climatic  condi- 
tions, and  whether  or  not  the  patient  is  a  native  of  the  country  where 
the  disease  was  contracted. 

The  routes  of  infection  followed  by  entamebse  in  their  migration  to 
the  liver  are  not  positively  known,  but  it  is  quite  probable  that  they 
reach  the  substance  of  the  organ  in  several  ways — viz.:  (i)  Directly 
from  the  intestine  by  way  of  the  duct;  (2)  through  the  portal  circula- 
tion ,after  having  gained  entrance  to  its  radicals  in  the  submucosa 
where  the  infective  process  is  most  active;  (3)  transperitoneally  from 
the  localized  lesions  in  the  gut;  (4)  the  general  circulation,  evidence  of 
which  has  been  the  finding  of  entameb»  in  the  vena  cava  and  right 
side  of  the  heart;  and  (5)  lymph-channels. 

Since  hepatitis  and  liver  abscess  are  rarely  present  in  the  early 
stages  of  dysenten,',  and  do  not  occur  until  ulcers  have  formed,  it 
would  seem  that  the  blood  and  hniph  circulations  are  important 
carriers  of  entamebie  from  the  bowel  to  the  liver. 

While  the  manifestations  of  li\er  abscess  have  been  encountered 
in  the  various  stages  of  entamebic  dysentery,  they  rarely  appear  before 
the  sixth  week,  and  usually  the  indications  of  suppuration  within  the 


HEPATIC    KNTAMEBIC    (tROPICAL)    ABSCESS 


v3"0 


organ  arc  not  apparent  in  latent  or  chronic  cases  for  several  months 
or  years  following  infection. 

Kartulis  observed  liver  abscess  in  55  per  cent.  (400  autopsies); 
Zancarol,  in  59  per  cent.  (444  cases) ;  Woodward,  in  21  per  cent.  (3680 
collected  cases);  Smith,  in  84.4  per  cent.  (45  cases);  Councilman  and 
Lafleur,  in  21  per  cent.  (1429  collected  cases);  Musgrave,  in  22.6  per 
cent.  (119  cases) ;  and  Craig,  in  5  per  cent.  (745  cases) ;  and  also  33  per 
cent,  in  a  series  of  78  fatal  cases  of  amebic  dysentery-. 

Strangely,  and  for  no  explainable  reason,  women  and  children  suffer- 
ing from  dysentery  have  liver  abscess  proportionately  ver\-  much  less 
frequently  than  men. 

The  published  records  indicate  that  in  from  75  to  80  per  cent,  of 
all  cases  of  tropical  (liver)  abscess  entamebcB  (Entamoeba  histolytica) 
are  demonstrable  in  the  dejecta,  or  a  history  of  the  patients  having 
previously  had  dysentery  can  be  obtained. 

X umber,  Size,  and  Location  of  Liver  Abscesses. — Entamebic  hepatic 
abscesses  may  be  single  or  multiple,  and  when  there  is  more  than  one 
the  number  may  vary  anywhere  from  two  to  thirty.  Zancarol  found 
liver  abscesses  single  in  60.2  per  cent.  (562  Egyptian  cases),  and 
Rodgers  observed  multiple  abscesses  in  32  per  cent,  of  the  patients 
treated  by  him  in  India. 

TABLE  SHOWING  THE  NXMBER  AND  LOCATION  OF  ABSCESSES  IN 
TWENTY-FOUR  FAT.AL  INFECTIONS  WITH  ENTAMCEBA  HISTOLYTICA 
OBSERVED  BY  CRAIG. 


Number  of 
cases. 


2 
3 
4 
5 
6 

7 
8 

9 
10 


13 
14 
15 
16 

17 
18 

19 
20 


23 
24 


Single. 


yes 
yes 

yes 


yes 


yes 
yes 


yes 


\es 
yes 


Multiple. 


Xumber. 


Location. 


yes 
yes 
yes 
yes 
yes 


yes 


yes 
yes 


yes 

yes 
yes 

yes 
yes 
yes 


4 
13 


17 
Too  numer- 
ous to 
count. 

10 


Ver>'    nu- 
merous. 

I 

30 

4 


Right  lobe.  5 
Right  lobe.  8 
Right  lobe.  3 
Right  lobe.  8 
Right  lobe.  8 
Right  lobe,  o 
Right  lobe,  o 
Right  lobe,  2 
Lobus  spigelii 
Right  lobe.  16 


left  lobe.  I 
left  lobe,  o 
left  lobe.  I 
left  lobe.  5 
left  lobe,  o 
left  lobe.  I 
left  lobe.  I 
left  lobe,  o 

;  left  lobe,  i 


In  both  lobes 
Right  lobe,  2; 
Right  lobe,  i ; 
Right  lobe,  3; 
Right  lobe,  5; 
Right  lobe,  o; 
Right  lobe,  3 ; 
Right  lobe,  i ; 
Right  lobe,  i; 


Right  lobe,  all 
Right  lobe,  i; 
Right  lobe.  23 
Right  lobe.  4; 
Right  lobe,  i ; 


left  lobe,  8 
left  lobe,  o 
left  lobe,  o 
left  lobe,  o 
left  lobe.  I 
left  lobe,  o 
left  lobe,  o 
left  lobe,  o 

but  2 

left  lobe,  o 
;  left  lobe.  7 
left  lobe,  o 
left  lobe,  o 


366 


ENTAMEBIC    COLITIS,    DIARRHEA    IN 


Hepatic  abscesses  may  be  microscopic,  moderate,  or  enormous  in 
size,  and  the  pus  accumulations  may  be  small  in  one  or  considerable 
in  another  section  of  the  liver,  and  the  abscesses  in  different  cases  may 
be  located  in  the  various  lobes  of  the  organ,  though  the  upper  right 
lobe  is  most  frequently  involved. 

In  a  series  of  639  cases  of  hepatic  abscess  collected  by  Rouis  the 
lesion  was  located  in  the  right  lobe  in  17.8  per  cent.;  in  the  left  lobe, 
13.3  per  cent.;  and  in  the  lobus  spigelii  in  0.3  per  cent,  of  the  cases. 

Tropical  liver  abscesses  may  remain  for  a  long  time  or  assume 
enormous  proportions  without  leaving  their  confines  in  some  instances, 
while  in  others  they  rupture  early  as  the  result  of  coughing  or  vomit- 
ing when  small  or  large,  and  the  pus  finds  its  way  into  adjacent 
structures  and  organs.  Most  often  the  abscess  breaks  into  the  pleura, 
pericardium,  or  lung,  and  less  frequently  pus  is  discharged  into  the 
peritoneal  cavity,  inferior  vena  cava,  colon,  stomach,  kidney,  or  lum- 
bar region.  Brown  says  that  approximately  10  per  cent,  of  untreated 
abscesses  burst  into  the  colon  and  i  per  cent,  into  the  small  bowel. 

The  following  table,  arranged  by  Craig,  enables  one  to  form  some 
idea  as  to  the  organs  into  which  liver  abscesses  most  frequently  rup- 
ture, and  the  proportion  of  cases  in  which  this  complication  arises: 


TABLE  ILLUSTRATING  THE  SITE  OF  RUPTURE  IN  AMEBIC   ABSCESSES 

OF  THE  LIVER. 


Observers. 

Cases 

of 

liver 

abscess. 

Cases 

of 

rupture. 

Peri- 
car- 
dium. 

Pleura. 

Lung. 

Colon.     Sto- 

Bile- 
ducts. 

Vena 
cava. 

Kidney. 

Lum- 
bar 
region. 

Waring 

Dutroulau . . . 

Rouis 

Haspel 

Camboy 

Howard 

Craig 

300 
66 

162 
25 
10 
6 
24 

68 
25 
54 
6 
3 
5 
7 

14 

2 

II 

4 

5 
2 

28 
10 
17 

2 
2 

5 

IS 

7 

14 

2 
I 
3 

I 
I 
6 

I 
2 

3 

2 

2 
4 

HiSTOPATHOLOGY  OF  Entamebic  Liver  Abscess. — The  liver  is 
considerably  swollen  when  there  is  hepatitis,  and  characterized  by 
diminutive  and  small  or  nodulated  enlargements  when  abscesses  are 
forming  or  pus  collections  are  already  present.  In  the  beginning  such 
raised  areas  are  light  colored,  bloodless,  and  firm,  and  where  sectioned 
present  a  lardaceous  appearance  and  contain  a  grayish,  semisolid  fluid 
matter.  The  small  tumors  become  encysted  or  coalesced  to  form  larger 
swellings,  the  centers  of  which  degenerate  and  form  abscesses,  which, 
when  incised,  are  found  microscopically  and  macroscopically  to  con- 
tain a  semifluid  yellowish  or  chocolate  red  matter,  broken-down  liver 
cells,  shreds  of  necrotic  tissue,  red  blood-corpuscles,  scattering  pus-cells, 
and  entameba'  when  the  disturbance  is  due  solely  to  entamebic  infec- 
tion. Where  the  trouble  is  due  to  mixed  infection  the  abscess  cavity  is 
filled  with  ordinary  or  greenish-looking  pus,  in  which  are  to  be  found 
entamebae,  streptococci,  staphylococci,  colon  bacilli,  and  other  organ- 


HEPATIC    EXTAMEBIC    (tROPICAL)    ABSCESS  367 

isms  concerned  in  tlie  septic  process.  In  some  instances  the  discliarge 
is  redflish  and,  according  to  Brown,  has  a  gelatinous  consistency  and  a 
"H\-erish"  smell;  in  others  and  when  bile  stained  it  possesses  a  green- 
ish hue,  but  when  colon  bacilli  are  acti\-e  it  has  a  decidedly  fecal 
odor. 

Hepatic  abscesses  ma\-  remain  isolated  or  ruj)ture  into  each  other 
through  coughing,  pressure,  or  sloughing  until  one  or  more  enormous 
ca\"ities  are  tormed  within  the  li\er  lobe.  The  retaining  walls  contain 
entamebaj  and  may  be  rough  as  a  result  of  undetached  shreds  or  larger 
pieces  of  necrotic  tissue,  or  smooth  when  the  abscess  has  existed  for  a 
long  time.  Occasionally  the  vessels  and  connective  tissue  of  the  liver, 
which  resist  the  suppurative  process  more  strongly  than  the  liver 
substance,  are  to  be  found  stretched  partially  or  completely  across 
small  or  large  abscess  cavities.  Usually  the  walls  of  moderately  small 
pus  cavities  are  smooth,  and  those  of  diminutive  abscesses  cannot  be 
defined. 

The  tissue  concerned  in  liver  abscess  when  sectioned  and  micro- 
scopically examined  presents  a  varied  appearance  in  the  different  stages 
of  the  disease.  At  first  there  is  congestion  of  the  part  and  an  accumu- 
lation of  white  blood-corpuscles,  connective-tissue  cells,  and  occa- 
sionally entameba?,  and  later,  as  degeneration  takes  place  in  the  center 
of  the  swelling,  necrotic  tissue,  fluid  or  semisolid  matter,  epithelium, 
white  blood-corpuscles,  micro-organisms,  and  lymphoid  cells  are 
demonstrable.  Newly  formed  bile  channels  are  often  observed,  and 
examination  of  the  periphery  of  the  small  abscesses  shows  that  the 
process  commences  in  the  interlobular  areas.  The  wall  of  these  ab- 
scesses is  formed  by  connective  tissue  considerably  infiltrated  by  leuko- 
cytes and  young  connective-tissue  cells,  and  entamebai  may  sometimes 
be  demonstrated  within  it.  The  liver  cells  in  the  immediate  vicinity 
undergo  necrosis,  the  capillaries  are  congested,  and  the  bile-ducts  are 
often  obliterated  or  encroached  upon  by  rapidly  growing  connective 
tissue.  In  large  abscesses  which  have  a  rather  thick  wall,  sections 
show  more  or  less  necrotic  material  at  the  inner  border,  while  externally 
fibrous  tissue  is  very  marked  and  resembles  granulation  tissue,  the 
cells  of  which  are  mostly  uninuclear.  More  externally  there  is  a  layer 
of  less  dense  connective  tissue,  infiltrated  with  spindle  and  small  round 
connective-tissue  cells.  This  infiltration  varies  with  the  age  of  the 
abscess,  and  when  the  fibrous  wall  is  very  thick  the  infiltration  is  not 
as  great  as  where  the  fibrous  tissue  is  of  more  recent  formation. 

The  entamebic  found  in  the  abscess  wall  in  the  zone  of  necrosis  are 
generally  near  the  border  of  the  connective-tissue  portion  of  the  wall, 
which  is  infiltrated  by  small  round  cells.  From  this  it  will  be  seen  that 
entamebcC  are  seldom  found  in  old  abscesses  showing  little  necrosis  and 
a  \ery  thick,  dense,  fil)rous  wall.  They  are  found  most  often  in  medium- 
sized  abscesses,  presenting  evidences  of  marked  necrosis  of  the  liver 
tissue  (Craig). 

Since  entamebcC  are  usually  demonstrable  in  the  pus  or  walls  of 
small  and  large  abscess  cavities  in  almost  ev'ery  instance,  and  since 


368  ENTAMEBIC    COLITIS,    DIARRHEA    IN 

mixed  infection  occurs  in  only  about  50  per  cent,  of  the  cases  of  liver 
abscess,  there  can  be  but  little  doubt  that  entamebce  are  the  specific 
cause  of  this  disease,  and  that  later  streptococci,  staphylococci,  colon 
bacilli,  and  others  of  the  intestinal  pathogenic  and  pyogenic  organisms 
participate  in  the  infection  to  the  further  detriment  of  the  patient's 
health.  In  this  connection  it  is  interesting  to  note  that  a  number  of 
cases  have  been  recorded  where  entamebae  have  been  carried  by  the 
blood  to  other  regions  than  the  liver,  which  became  infected  and  ab- 
scesses formed. 

Symptoms  and  Diagnosis. — The  symptoms  and  complications  are 
variable  in  different  cases,  depending  upon  the  duration,  number,  and 
size  of  the  liver  abscesses  and  manifestations  of  the  accompanying 
colitis.  Tropical  hepatic  abscesses  may  develop  in  a  few  weeks,  or 
take  months  or  years  to  form  and  produce  definite  symptoms,  or  they 
may  become  encysted  and  remain  indefinitely  without  causing  the 
patient  any  trouble.  In  some  instances  a  hepatitis,  which  eventually 
results  in  the  formation  of  an  abscess,  may  occur  shortly  following 
entamebic  infection  of  the  bowel,  months  later,  or  not  until  the  dys- 
entery has  been  apparently  cured.  In  addition  to  the  usual  dysenteric 
symptoms,  the  patient  gives  a  history  of  having  suffered  from  chilly 
sensations,  followed  by  a  temperature  of  103°  to  104°  F.  The  tempera- 
ture may  be  normal  at  one  time  and  high  at  another,  and  these  patients 
exhibit  the  usual  indications  of  sepsis — viz.,  malaise,  headaches,  night- 
sweats,  sallow  complexion,  and  lack  of  desire  for  work  or  pleasure.  In 
addition  to  tenderness  over  the  colon  these  sufferers  complain  of  more 
or  less  severe  pain  in  or  near  the  liver,  particularly  in  the  subcostal 
region  or  midaxillary  line  near  the  ninth  rib.  When  the  abscess  is 
forming  pain  is  frequently  of  a  sharp,  shooting,  or  stabbing  character 
and  is  felt  in  the  affected  liver  lobe,  but  when  formed  and  considerable 
pus  has  accumulated  it  is  dull,  disseminated  throughout  the  hypochon- 
driac region,  and  is  felt  in  the  back  or  right  shoulder.  The  tumor 
causes  sensations  of  fulness,  weight  and  pressure,  and  is  the  cause  of 
much  discomfort  during  respiration,  when  the  liver  is  bound  to  adja- 
cent structures  by  adhesions.  Naturally,  the  local  and  reflex  pains 
induced  by  multiple  are  more  frequent  and  severe  than  those  caused 
by  equal  sized  single  abscesses.  Discomfort  in  the  epigastric  region 
and  disturbed  digestion  are  often  concomitant  symptoms. 

Tropical  liver  abscess  patients,  owing  partially  to  the  local  lesions 
in  the  bowel,  septic  condition  in  the  liver,  and  exhausting  diarrhea, 
appear  very  ill,  are  greatly  emaciated,  have  a  muddy,  unhealthy  com- 
plexion, flabby  skin,  muscular  weakness,  discolored  conjunctiva,  and 
suffer  from  emaciation,  nervousness,  insomnia  and  indigestion,  ex- 
haustion, interference  with  the  respiration,  and  occasionally  coughing, 
pleuritis,  or  pneumonia. 

The  urinary  chlorids  and  urobilin  are  increased  and  urea  is  dimin- 
ished in  the  presence  of  liver  abscess,  and  albumin  may  be  present  in 
the  urine  when  sepsis  is  marked  and  the  patient  continuously  exhibits 
a  high  temperature. 


HEPATIC    ENTAMEBIC    (TrU)PICAL)    ABSCESS  369 

While  polymorphonuclear  leukocytosis  is  occasionally  noticeable 
in  the  later  stages  of  the  disease,  it  is  not  to  be  relied  upon  as  a  diagnostic 
sign.  Brown  says  the  total  number  of  leukocytes  is  usually  high  and 
varies  from  fifteen  to  twenty  thousand. 

When,  as  the  result  of  distention  or  coughing,  a  liver  abscess  rup- 
tures into  the  lung  the  patient  expectorates  greenish  or  chocolate- 
colored  matter,  which  contains  necrotic  tissue,  pus-cells,  liver  sub- 
stance, entameba-,  and  pyogenic  bacteria.  Abscesses  which  burst  into 
the  abdomen  induce  peritonitis  and  often  cause  death;  those  which 
open  into  the  pericardium  greatly  interfere  with  the  heart's  action, 
but  when  they  discharge  into  the  bowel,  troublesome  manifestations 
seldom  arise.  For  the  treatment  of  entamebic  or  tropical  liver  abscess 
see  Chapter  XXXII. 

24 


CHAPTER  XXXI 

ENTAMEBIC    COLITIS    (ENT AMEBIASIS,    ENT AMEBIC    DYS- 
ENTERY),  DIARRHEA   IN    {Continued) 

DIAGNOSIS,   PROGNOSIS 

Diagnosis. — In  this  class  of  cases  the  main  thing  is  to  differentiate 
entanu'hic  from  other  forms  of  colitis,  but,  as  a  rule,  this  can  be  accom- 
l)lishe(l  without  serious  lr()ui)le  by  obtaining  a  complete  history,  finding 
out  whether  or  not  tlie  patient  is  or  has  been  living  in  the  tropics,  lands 
or  sections  of  the  world  where  entamebiasis  is  endemic,  analyzing 
tlic  (Kseiiteric  s\ini)l()ms,  inspecting  the  bowel  through  the  procto- 
scoiH',  and  exaniining  the  dejecta. 

When  it  is  borne  in  mind  that  patients  afflictetl  with  bacillary, 
helminlliic,  balantidic,  coccidic,  schistosomic,  ciliate,  or  flagellate 
colitis  complain  of  manifestations  similar  to  those  of  entamebic  dysen- 
tery, the  importance  of  thoroughly  examining  the  stools  for  entamebae 
and  other  specilic  organisms  and  worms  is  obvious.  The  finding  of 
enlamel)a>  is  not  conclusi\  e  thai  the  jiatient  suffers  solely  from  en- 
tamebic colitis,  because  harmless  iMilanKrba  coli  are  often  present, 
and  occasionally  patients  suffer  froiu  a  mixed  infection  participated  in 
by  entameba",  Shiga,  I'dexner,  or  other  bacilli,  Balantidium  coli,  hel- 
minths, etc.,  which  can  be  isolated  by  carefully  examining  through  the 
microscope  the  feces,  dischargt's,  or  scrapings  from  the  lesions.  I'nder 
such  circuiustances,  without  disc()\'ery  of  the  specilic  agents  causing 
the  trouble,  a  diagnosis  is  confusing  because  the  symptoms  of  the 
different  types  of  infection  are  marked  or  become  blended  and  difficult 
to  distinguish.  Acute  is  easib'  recognized,  but  chronic  entamebic  d\'s- 
enter>-  isdiflicult  to  diagnose  because  the  colonic  tenderness,  diarrhea, 
straining,  pus,  blood,  and  nuicus  in  the  stools  and  other  manifestations 
conse(|uent  \\\)o\\  it  may  clovSeK  resemble  those  induced  l)y  chronic 
catarriial  cnlcrocolilis,  /jcrsistenl  dietary  iii(liscrctio)is,  digestive  disturb- 
ances, i^onorrheal,  Ixtlantidic,  syphilitic,  bacillary,  or  tubercular  colitis, 
stricture,  cancer,  /)oly/)i,  and  intestinal  obstruction,  bilharziasis  of  the 
rectum,  hemorrhoids,  heniorrluij^es,  helminths,  etc.,  and  because  the 
disease  is  freciuiMitb-  secondar\-  to  other  infections  or  diseases  which 
involve  the  bowel  locally  or  greatl\-  (K>plete  the  jiatient's  health — viz., 
such  as  typhoid,  t>phus,  and  scarlet  fe\ers,  cholera,  sepsis,  small-pox, 
etc.  Here,  as  in  other  stages  and  forms  of  chsenleric  colitis,  a  diagno- 
sis is  comparatively  easy  when  the  dejecta  is  examined,  and  entamebae, 
dysenteric  bacilli,  or  other  specific  agents  causing  the  infection  are 
isolated. 
370 


DIAGNOSIS  371 

A  microscopic  examineitit^n  of  the  feces  in  patients  sufTering  from 
bowel  disturbances  who  do  not  sufTer  from  diarrhea  or  blood  and  mucus 
in  the  stools  occasionally  demonstrates  the  presence  of  entameba-  in 
the  intestine  and  that  the  subject  has  a  latent  form  of  dysentery. 

The  lesions  of  entamebic  infection  are  manifest  as  numerous  large 
and  small  ulcers  of  the  mucous  membrane  which  connect  with  exten- 
sive intercommunicating  cavities  beneath  the  mucosa,  and  are  less 
seldom  seen  in  the  form  of  membranes  or  sloughs,  while  those  of  the 
hacillary  t\pe,  when  inspected  through  the  proctoscope,  usually  show 
as  a  catarrhal  intlammation,  suj^jcrficial  erosions  or  ulcers,  fliphtheric 
membranes,  or  gangrenous  sUnighs  of  the  mucosa.  Finally,  entamebic 
colitis  may  be  differentiated  from  the  bacillary  iovnx  by  its  more  insid- 
ious onset,  occasional  latency,  absence  of  early  and  profound  toxic 
manifestations  (high  fever,  rapid  emaciation,  delirium,  coma,  etc.), 
greater  tendency  toward  chronicit\-,  and  because  it  occurs  less  often 
in  epidemic  form,  is  not  so  frequenil\-  encountered  among  the  inmates 
of  asylums,  barracks,  prisons,  and  poor-houses;  constitutional  symp- 
toms do  not  usually  appear  in  the  beginning  of  the  disease  and  the 
mortality  is  highest  in  the  later  stages,  while  in  bacillary  colitis  death 
is  most  common  within  three  or  four  days  or  a  week. 

Finally,  liver  abscess,  a  common  complication  of  entamebiasis, 
never  occurs  in  bacillary  dysentery  except  in  the  presence  of  a  mixed 
infection,  strictures  and  secjueUe  are  very  much  more  frec}uent  in  the 
former  than  the  latter,  and  entamebic  infection  is  usually  confined  to 
the  colon,  while  that  of  the  bacillary  type  more  often  extends  well  u[) 
in  the  lower  ileum. 

Examination  of  the  stools  is  \er\-  important  and  should  be  practised 
as  a  routine  measure  in  all  suspected  cases  of  entamebiasis. 

By  a  macroscopic  examination  one  can  determine  the  color,  amount, 
and  consistence  of  the  evacuations  and  whether  or  not  they  contain 
pus,  blood,  mucus,  membranous,  and  gangrenous  tissue,  undigested 
food  remnants,  foreign  bodies,  or  large  worms  of  the  round,  tape,  and 
other  varieties,  but  he  cannot  detect  in  this  way  the  more  minute 
organisms  which  cause  dysenteric  colitis. 

A  microscopic  examination  is  very  much  more  reliable,  and  is  an 
imperative  diagnostic  aid  in  this  class  of  cases,  because  when  a  speci- 
men of  feces  has  been  obtained  in  the  right  way,  properly  prepared  and 
mounted,  and  is  carefully  inspected  through  the  microscope,  a  positive 
diagnosis  is  possible,  since  harmless  (Entamoeba  coli)  and  pathogenic 
entamebae  (Entamoeba  histolytica),  dysenteric  bacilli  (Shiga,  Kruse, 
Flexner,  Park,  Duval,  Hiss,  etc.),  diminutive  and  larger  helminths 
(with  their  ova),  schistosoma,  Balantidium  coli,  ciliates,  flagellates, 
and  coccidia,  the  acti\e  etiologic  factors  in  the  different  types  of 
dysenteric  colitis,  can  be  detected. 

Entamebae  are  prone  to  be  overlooked  when  dead,  but  when  motile 
they  are  easy  to  distinguish,  and  are  interesting  to  study  because  of 
the  variations  in  extension  of  their  pscudopodia  and  their  method  of 
locomotion  when  traveling  from  one  point  to  another. 


372  ENTAMEBIC    COLITIS,    DIARRHEA    IN 

The  best  results  are  accomplished  by  examining;  the  feces  while 
fresh  and  warm  in  a  room  comfortably  heated  and  with  the  slide  upon  a 
warm  stage  when  the  life-cycle  of  the  organism  is  to  be  studied,  and  upon 
an  ordinary  stage  when  the  finding  of  entameba?  is  all  that  is  desired.^ 
Preferably,  salts  should  be  administered  several  times  previous  to  the 
examination  to  wash  the  specific  agents  free  of  the  mucosa,  a  fluid 
should  bj  selected  over  a  semisolid  specimen,  and  the  mucus  should 
be  diluted  as  occasion  demands  to  keep  it  from  drying  and  the  enta- 
mebae  active  as  long  as  may  be  required.  Usually,  it  is  advisable 
to  examine  the  dejecta  of  from  six  to  ten  stools  by  the  ordinary  or 
drop  method,  to  determine  if  specific  agents  are  always  present,  their 
number,  and  whether  or  not  they  are  associated  with  bacilli  or  other 
dysentery-producing  micro-organisms.  For  routine  purposes  staining 
is  not  required  because  entamebte  can  be  differentiated  from  red 
blood-cells  by  their  much  larger  size  (4  to  8  cm.),  epithelial  cells, 
pseudopodia,   and   active  protoplasmic  motion. 

Feces  admixed  with  urine  and  that  which  has  been  disinfected  or 
obtained  from  patients  who  have  been  irrigating  the  bowel  with  stimu- 
lating or  astringent  agents,  or  have  taken  antiseptic  medicines,  is  unfit 
for  microscopic  examination,  because  if  entameba  are  present  they  will 
be  inactive  or  dead  and  difficult  to  locate.  Where  the  stool  is  to  be 
brought  to  the  office  or  hospital  it  can  be  kept  at  a  proper  temperature 
by  placing  it  in  a  Thermos  or  a  small  bottle  which  is  dropped  into  a 
larger  one  filled  with  warm  water,  but  when  an  immediate  examination 
is  to  be  made  the  feces  may  be  evacuated  into  a  warm  bed-pan. 

While  it  is  customary  to  examine  the  dejecta  for  the  organisms, 
entameba;  are  frequently  found  in  the  voided  thin  or  gelatinous  mucus, 
scrapings  taken  from  the  edges  and  base  of  ulcers,  and  sections  removed 
from  the  bowel  at  the  site  of  the  lesions,  but  the  author  has  obtained 
the  best  results  from  specimens  obtained  by  the  curet  used  through 
the  proctoscope. 

With  care  and  the  aid  of  the  microscope  a  positive  diagnosis  can 
be  made  in  nearly  every  case,  a  fact  demonstrated  by  the  author's 
findings,  which  are  in  harmony  with  those  of  Hanes,  who  detected 
motile  entamebcC  in  each  of  24  cases. 

With  the  exception  of  the  harmless  Entama'ba  coll,  other  organisms 
of  this  class  {E.  histolytica)  are  pathogenic  and  under  favorable  con- 
ditions produce  entamebic  colitis.  In  so  far  as  the  diagnosis  of  dys- 
entery is  concerned,  the  differentiation  between  the  various  entamebse 
is  uncalled  for,  but  scientifically  the  one  can  be  distinguished  from  the 
other  by  studying  their  morphology  and  methods  of  reproduction  and 
by  observing  their  motility,  since  it  is  claimed  that  pathogenic  are 
very  much  more  active  than  the  non-pathogenic  E.  coli. 

In  summing  up  his  conclusions  regarding  the  points  of  differentia- 
tion between  the  various  entamebae,  Craig"  says,  "If  in  a  freshly  voided 

'  For  further  particulars  relating  to  examinations  of  the  stools  see  Walker,  Phil.  Med. 
Sci.,  August  13,  1Q13. 

'^  The  Parasitic  Amcb;e  of  Man,  p.  197,  igii. 


DIAGNOSIS    OF    LIVKR    ABSCESS 


373 


specimen  of  feces  we  observe  amebic  showing  sluggish  motility,  no 
distinction  between  the  ecto-  and  endoplasm,  or  a  very  slight  distinc- 
tion, and  the  presence  of  a  nucleus  having  a  well-defined  nuclear 
membrane  and  containing  much  chromatin,  we  may  diagnose  the 
organism  as  Entamceba  coli;  under  the  same  conditions,  if  we  observe 
an  ameba  which  is  actively  motile,  presents  a  clear,  glass-like  ecto- 
plasm sharply  distinguished  from  the  endoplasm,  and  a  nucleus 
having  a  well-defined  nuclear  membrane  and  a  clear  area  surrounding 
the  centriole,  or  a  nucleus  is  absent,  or,  if  present,  shows  no  nuclear 
membrane  and  but  little  chromatin,  the  diagnosis  will  be  E.  histo- 
lytica.'' 

When  inspected  at  autopsy  or  through  the  sigmoidoscope  the  lesions 
of  acute  and  subacute  entamebic  colitis  are  fairly  characteristic  and 
can  be  readily  differentiated  from  bacillary  infection,  but  in  chronic 
cases  accompanied  by  mixed  injection  the  task  is  less  easy,  because 
lesions  consequent  upon  the  specific  and  pathogenic  micro-organisms 
of  the  intestine  are  somewhat  similar  in  both  v^arieties  of  dysentery. 
Entamebic  ulcers  in  process  of  formation  show  as  elevated  reddish 
dots  on  the  summit  of  the  mucous  folds,  which  later  assume  a  grayish 
or  darker  hue  when  on  the  point  of  breaking  down,  or  as  superficial 
linear  erosions  which  cross,  coalesce,  and  undergo  necrosis  to  form  the 
classic  stellate  dysenteric  ulcers.  In  neglected  cases  the  raw  areas 
(ulcers)  are  variable  in  shape,  size,  and  depth,  have  a  grayish  necrotic 
base,  reddish,  raised,  undermined  edges,  and  lesions  upon  the  mucosa 
connect  with  extensive  ca\"ities  beneath  the  mucosa,  forming  collar-but- 
ton-shaped ulcers.  Frequently  the  excavated  areas  beneath  the  mu- 
cous membrane  join  to  make  larger  ones,  abscesses  form,  and  inter- 
communicating fistuhe  connect  the  one  with  the  other. 

Diphtheric  membranes  and  gangrene  of  the  mucosa  are  occa- 
sionally seen,  but  these  destructive  processes  complicate  bacillary 
ver\'  much  more  frequently  than  entamebic  colitis.  When  the  mucous 
membrane  is  invoked  by  a  catarrhal  entamebic  infection  it  is  extremely 
red,  swollen,  sensiti\e,  at  times  edematous,  and  is  besmeared  with  a 
thin,  clear,  or  thick  gelatinous  mucus.  When  the  inflammation  is  less 
active  and  ulcers  are  numerous,  small,  or  of  fair  size,  the  bowel  lining 
is  less  red  and  thick  and  is  abundantly  covered  with  mucus  admixed 
with  feces,  considerable  blood,  tissue  debris,  and  a  slight  amount  of 
pus,  but  in  chronic  dysentery  in  the  presence  of  extensive  lesions,  collar- 
button  ulcers,  submucous  abscesses,  and  fistulge,  the  mucous  membrane 
is  constantly  bathed  in  yellow  pus  or  a  reddish-tinted  discharge,  com- 
posed largely  of  pus,  blood,  and  mucus,  and  is  sometimes  covered  with 
a  diphtheric-like  or  fibrinous  membrane  or  undergoes  gangrenous 
changes,  and  looks  black  or  is  to  be  seen  hanging  from  the  bowel  in 
the  form  of  necrotic  strips  or  pieces. 

Diagnosis  of  Liver  Abscess. — ^Knowing  the  patient  has  or  suff'ers 
from  entamebic  d\senter\-,  in  the  presence  of  the  above  symptoms,  and 
after  a  careful  examination,  it  is  comparatively  easy  to  diagnose  this 
condition,  but  in  cases  of  latent  dysenter>',  and  where  the  abscess  forms 


374  ENTAMEBIC    COLITIS,    DIARRHEA    IN 

insidiously  and  the  symptoms  of  both  infections  are  massed,  the 
presence  of  suppurative  foci  in  the  Hver  are  often  extremely  difficult 
or  impossible  to  detect.  Usually  in  these  cases  the  entire  liver  or  some 
of  its  lobes  are  tender,  enlarged,  and  can  be  felt  or  seen  bulging  beyond 
their  normal  confines,  and  when  pressed  upon  cause  the  patient 
considerable  pain. 

Formerly  the  aspirator  was  frequently  employed,  but  this  method 
of  diagnosis  is  unscientific  and  dangerous  and  should  be  discarded. 
Naturally,  in  patients  who  suffer  from  colitis  and  disturbances  within 
the  liver  the  finding  of  entamebtc  in  the  dejecta  points  strongly  to  liver 
abscess,  and  more  particularly  when  the  patient  exhibits  the  usual 
manifestations  of  sepsis. 

Empyema,  malaria,  suppuration  within  the  gall-bladder,  kidney 
lesions,  hydatids,  subphrenic  abscesses,  and  other  diseases  of  the  neigh- 
boring organs  have  at  one  time  or  another  been  mistaken  for  liver 
abscess,  but  with  our  present  knowledge  the  diagnosis  of  this  condition 
is  in  most  instances  made  without  much  difficulty. 

Prognosis. — The  prognosis  is  good  in  some  and  unfavorable  in  other 
cases,  depending  upon  the  virulence  of  the  infection,  condition  of  the 
patient  when  attacked,  duration  of  the  disease  (for  it  may  run  an  acute, 
subacute,  or  chronic  course),  and  whether  or  not  patients  are  neglected  or 
ignorantly  treated.  When  properly  handled  under  favorable  conditions 
entamebic  colitis  rarely  ends  fatally,  but  the  prognosis  is  bad  when  the 
patient  has  not  had  proper  care  until  the  disease  has  almost  com- 
pletely destroyed  the  colon,  invaded  the  liver,  or  led  to  mixed  infec- 
tion, and  in  persons  afflicted  with  tuberculosis,  liver,  or  other  affections 
which  destroy  their  digestion  and  vitality. 

The  author  has  lost  no  uncomplicated  cases  of  the  disease;  hence, 
with  the  above-named  exceptions,  he  considers  the  ultimate  prognosis 
of  entamebic  dysentery  good  when  the  patient  is  treated  according  to 
the  plans  outlined  elsewhere. 

It  is  extremely  difficult,  however,  to  give  a  prognosis  as  regards  the 
time  necessary  to  effect  a  cure,  because  from  what  has  been  intimated 
it  may  be  inferred  that  in  a  series  of  cases  it  may  take  days,  weeks, 
months,  or  longer  to  completely  eradicate  the  disease  and  prevent 
relapses. 

Some  patients  completely  cured  of  dysentery  continue  to  regu- 
larly or  intermittently  suffer  from  indigestion  or  diarrhea  owing  to 
their  nervous  state,  or  the  irritable  condition  in  which  the  gastro-in- 
testinal  tract  has  been  left. 

Prognosis  of  Liver  Abscess. — Where  the  dysentery  has  been  cured 
or  it  remains  quiescent,  and  there  is  but  one  or  two  small  or  a  single 
large  liver  abscess,  patients  make  a  very  good  or  complete  recovery, 
providing  the  abscesses  are  promptly  incised  and  drained.  Unfortu- 
nately, those  afflicted  with  liver  abscess  consequent  upon  entamebic 
colitis  arc  usually  exhausted  as  a  result  of  a  long-continued  diarrhea, 
loss  of  blood,  and  their  septic  condition,  or  suffer  from  one  or  more 
enormous  abscesses  which  have  destroyed  considerable  areas  of  the 


PROGNOSIS    OF    LIVER    ABSCESS  375 

liver  substance  and  are  operated  upon  with  great  difficulty.  Brown 
sa>'s  that  irom  30  to  40  per  cent,  of  all  cases  of  postdysenteric  abscess 
of  the  liver  prove  fatal  in  spite  of  the  modern  surgical  procedures,  but 
this  mortality  is  rather  hii^h.  Numerous  instances  have  been  recorded 
of  i)atients  who  have  recovered  following  operations  for  abscesses  which 
had  destroyed  the  lobes  of  the  liver  to  a  large  extent.  Much  better 
results  are  obtained  when  the  infection  is  regarded  as  dual  and  the  bowel 
and  liver  are  simultaneously  treated.  The  results  recently  obtained 
in  the  treatment  of  liver  abscess  leads  one  to  hope  that  the  mortality 
of  this  infection  will  l)e  greatly  reduced  in  the  future. 

While  much  hangs  on  the  surgical  technic  employed,  still   more 
depends  upon  the  early  recognition  and  operation  in  this  class  of  cases. 


CHAPTER  XXXII 

ENT AMEBIC    COLITIS    (ENT AMEBIASIS,    ENT AMEBIC    DYS- 
ENTERY),  DIARRHEA   IN  {Concluded) 

TREATMENT 
PROPHYLACTIC.    MEDICINAL.    IRRIGATING.    SURGICAL 

Treatment. — While  considerable  progress  has  been  made  relative 
to  the  etiology,  pathology,  and  method  of  handling  entamebic  colitis, 
thus  far  no  routine  treatment  effective  in  all  cases  has  been  discovered, 
and  there  is  no  unanimity  of  opinion  as  to  which  are  the  best  thera- 
peutic agents  to  employ  in  this  class  of  cases. 

The  treatment  must  be  prophylactic,  supportive,  medical,  local,  and 
surgical,  according  to  the  indications  in  a  given  case,  dependent  upon 
the  virulence  and  duration  of  the  infection,  degree  of  bowel  involve- 
ment, and  condition  of  the  patient's  general  health. 

Prophylactic  Treatment. — Prophylaxis  against  entamebic  dysentery 
is  important  in  this  country,  and  more  so  in  countries  where  the  disease 
is  endemic,  because  it  usually  results  from  the  ingestion  of  pathogenic 
entamebK  which  is  avoidable  when  due  precautions  are  taken.  To 
obviate  this  type  of  infection  or  prevent  its  spreading  when  endemic 
and  epidemic,  it  is  necessary — viz.,  (i)  to  drink  pure  bottled  or  water 
after  it  has  been  properly  filtered,  boiled,  and  placed  in  covered  con- 
tainers free  from  parasites  (when  contaminated) ;  (2)  consume  only 
vegetables  and  fruits  from  soils  which  have  not  been  contaminated 
through  fertilization  with  or  the  drainage  of  human  excreta;  (3)  when 
bathing  in  impure  water  to  prevent  its  entrance  into  the  mouth  or  the 
rectum;  (4)  avoid  ices  and  ice-cream  which  favor  encystment  of  con- 
tained entamebse,  which  may  later  infect  the  bowel,  (5)  disinfect  the 
dejecta  of  dysenteric  patients;  (6)  avoid  raw  and  improperly  cooked 
foods,  vegetables  and  salads,  cold  meat,  fish,  chicken,  etc.,  which 
have  been  carelessly  handled,  placed  in  unclean  dishes,  or  left  un- 
covered; (7)  use  care  in  the  handling  of  these  sufferers  by  isolating 
them,  washing  their  linen,  having  them  use  the  same  toilet,  screening 
their  excreta  from  flies  which  would  carry  the  infection  elsewhere,  and 
keeping  them  under  observation  and  treatment  for  a  reasonable  time 
after  an  apparent  cure,  because  they  may  be  carriers  of  entamebcc  and 
be  the  means  of  infecting  others. 

It  has  been  demonstrated  that  to  a  slight  degree  alcohol  and  acids 
minimize  the  danger  of  and  effects  of  entamebic  infection,  hence  it  is 
advantageous  for  strangers  visiting  tropical  countries  to  consume  in 
reasonable  amounts  dilute  mineral  acids,  or  Hoch,  Moselle,  Sauterne, 
Graves,  and  like  wines  with  their  meals,  or,  in  their  absence,  whisky 
or  brandy  in  soda  and  aerated  watersi. 

37t> 


DIET  377 

The  chief  prophylactic  measures  consist  in  cleanliness,  avoidance 
of  contaminated  water  and  footl,  moderate  exercise  in  the  open  air, 
and  the  correction  of  local  or  general  manifestations  which  lessen 
resistance  and  render  the  subject  more  liable  to  infection,  and  change 
to  a  climate  where  the  disease  is  less  prevalent. 

Supportive  Treatment. — Supportive  measures  are  not  so  frequently 
indicated  in  acule  as  they  are  in  chronic  entamebic  colitis  (dysentery) 
where  the  patient  has  been  ill  for  a  long  time,  the  organs  imperfectly 
perform  their  functions,  and  he  is  weak  and  emaciated.  Mild  forms 
of  exercise  are  healthful,  of  which  none  is  better  than  walking,  but 
violent  exercise  is  contra-indicated  at  all  times,  and  one  should  be  less 
active  during  relapses  and  exacerbations.  Rest  in  the  house  and,  if  nec- 
essary, in  bed  during  acute  attacks  and  in  the  subacute  and  chronic 
varieties  is  necessary  when  experience  has  demonstrated  that  getting 
up  or  attempts  at  work  or  going  about  exaggerates  the  dysenteric 
symptom-complex,  for  some  patients  remain  apparently  well  while  in 
bed  and  have  relapses  when  about.  It  is  also  advisable  to  keep  very 
weak  and  emaciated  patients  as  quiet  as  possible,  particularly  when 
they  have  heart  complications.  The  author  has  found  that  the 
average  individual  afflicted  with  chronic  and  subacute  dysentery 
improves  faster  and  retains  his  strength  better  when  he  is  permitted  to 
exercise  moderately  in  the  open  air  or  attend  to  business  (when  it  is 
not  too  arduous)  except  during  exacerbations.  Since  diarrhea  pre- 
vails both  when  the  patient  is  quiet  or  up  and  alxjut,  it  is  best  to  keep 
him  out  of  bed  to  avoid  weakness  and  improve  his  mental  state. 

Dysenteric  subjects  should  be  properly  clothed  and  kept  warm,  and 
should  be  warned  against  exposure,  cold  bathing,  and  ice-cold  drinks. 

Diet  constitutes  an  important  part  of  the  treatment  in  some,  but 
not  in  all  cases.  It  is  imperative  that  the  diet  be  controlled  in  acute 
and  during  sharp  attacks  of  chronic  entamebic  colitis,  but  patients  who 
have  suffered  long  from  dysentery  are  often  harmed  by  having  them 
stick  to  a  rigid  fluid  diet,  and  the  author  makes  it  a  practice  to  allow 
them  as  much  mixed  food  as  they  can  properly  digest  to  avoid  the 
malnutrition  which  accompanies  a  purely  fluid  diet.  It  is  advisable 
to  have  these  patients  eat  more  frequently,  consume  less  food  at  each 
meal  than  normally,  and  select  nutritious  articles  of  diet  which  will 
make  up  the  loss  to  the  body  due  to  their  protracted  illness.  In  very 
acute  dysentery  the  intestine  is  violently  inflamed,  and  it  is  advisable 
to  temporarily  stop  all  food  and  give  complete  rest  to  the  mucosa 
unless  some  nourishment  is  necessary  to  maintain  the  patient's  strength. 
Under  such  circumstances,  and  during  marked  exacerbations  of 
subacute  and  chronic  dysentery,  the  author  prescribes  fluid  nutritive 
foods  and  prohibits  solid  and  irritating  articles  of  diet  or  those  which 
leave  a  coarse  fecal  residue.  While  the  patient  is  extremely  ill,  broths, 
chicken  soup,  whey,  egg-albumen,  and  barley-  or  rice-water  are  desir- 
able, but,  as  acuteness  of  the  attack  subsides,  milk  (plain),  sour, 
peptonized,  or  diluted  with  barley-water,  may  be  administered  in 
liberal  amounts  along  with  a  puree,  of  rice,  potatoes  or  beans,  extracts 


378  ENTAMEBIC    COLITIS,    DIARRHEA    IX 

of  beef,  or  the  juice  of  pressed  meat,  and  occasionally  macaroni  or  gra\'y. 
Later,  when  convalescence  is  e\ident,  soft-boiled  eggs,  weak  tea  or 
coffee,  milk- toast,  fresh  fish  (not  shell),  rare  roast  beef  and  mutton, 
butter,  and  easily  digested  and  non-irritating  vegetables  may  be  gradu- 
ally added  to  the  diet,  but  berries  and  fruit  should  be  prohibited  until 
the  acute  symptoms  have  completely  disappeared. 

In  chronic  dysentery  a  liberal  mixed  diet  is  indicated,  but  articles 
of  diet  difficult  to  digest  and  those  which  ferment  or  leave  an  abun- 
dant or  coarse  residue  are  contra-indicated,  and  foods  of  whatever  kind 
should  not  be  eaten  very  hot  or  very  cold,  because  extreme  heat  and 
cold  stimulate  peristalsis,  which  tends  to  increased  evacuations  or 
induce  enterospasm. 

In  long-standing  cases  meat  should  dominate  farinaceous  food  be- 
cause it  is  more  nutritious,  stimulates  an  active  flow  of  the  gastric  and 
intestinal  secretions,  and  thereby  minimizes  fermentation;  but  liver, 
kidneys,  sweetbreads,  and  preser\'ed  or  salted  fish  or  meat  are  undesir- 
able. Patients  soon  become  tired  of  meat  unless  it  is  varied  or  occa- 
sionally consumed  in  connection  with  carbohydrates.  Rare  beef  and 
mutton  are  more  easily  taken  care  of  than  when  they  are  well  done. 
Brawn^  says,  "As  an  auxilian,-  to  a  modified  meat  diet,  somatose.  a 
granular  tasteless  powder  which  is  soluble  in  water,  easily  digested,  and, 
for  its  bulk,  highly  nutritious,  is  one  of  the  most  useful  of  the  solid 
peptones;  while  of  the  casein  preparations  the  best  known  are  protene, 
which  appears  to  be  practically  pure  casein,  plasmon,  in  which  there 
is  over  80  per  cent,  of  protein;  and  sanatogen,  which  is  composed  of 
casein  and  about  5  per  cent,  of  added  glycerophosphate  of  soda.  Apart 
from  their  alimentary  value — casein,  bulk  for  bulk,  is  more  nutritious 
than  meat  protein — these  preparations  are  often  of  remarkable  service 
in  the  treatment  of  the  later  stages  of  amebic  dysentery,  and  are  spe- 
cially effective  in  counteracting  fermentation  and  checking  the  absorp- 
tion of  intestinal  toxins." 

The  following  is  a  specimen  of  a  modified  meat  diet  suited  to  the 
treatment  of  an  average  case  of  chronic  amebic  dysentery': 

7.30  A.  M.:  Tea,  with  milk  and  a  little  sugar;  no  bread.  An  orange,  a  few  grapes,  or 
a  pear. 

9  A.  M.:  Two  very  soft-boiled  eggs.  Tea  or  weak  coflPee  and  milk:  a  limited  quantity 
of  toast  and  butter.  If  eggs  cannot  be  taken,  fresh  fish  may  be  substituted;  and  protene 
or  sanatogen  may  be  given  instead  of  tea  or  coffee.  No  bacon,  ham,  or  preserved  fish  is 
allowed. 

11.30  A.  M.:  Ten  ounces  of  clear  soup,  with  plasmon  or  some  other  protein  prepara- 
tion. 

1.30  p.  M. :  SLx  ounces  of. underdone  roast  beef  or  mutton,  minced  beef,  chicken,  rab- 
bit, or  calf's  head,  or  game  with  macaroni,  green  vegetables,  or  tomatoes.  Any  stewed 
or  fresh  non-carbohydrate  fruit  in  season.  Strawberries  and  rhubarb  are  specially  suit- 
able.    Appolhnaris  or  Perrier  water. 

5  p.  M.:  Tea.  with  a  limited  quantity  of  brown  bread  and  butter. 

7.30  p.  M.:  Clear  or  JuUenne  soup;  a  little  dry  toast.  Fresh  fish  cooked  in  any  way, 
but  without  flour.  For  convalescents  (in  addition),  a  little  cold  meat,  chicken,  or  game. 
A  pear  or  other  fruit  in  season.     Appollinaris  or  other  table  water. 

10.00  p.  M.:  Ten  ounces  of  hot  water. 

1  Amebic  or  Tropical  Dysentery,  p.  225,  1911. 


MEDICAL    TREATMENT  379 

Buttermilk  and  other  sour  milks,  prepared  through  the  agency 
of  lactic  acid  bacilli,  are  palatable  and  frequently  serviceable  alone  or 
in  conjunction  with  other  foods  in  the  treatment  of  dysentery.  Alcohol 
and  wines  should  be  prohibited  except  when  stimulation  is  necessary 
or  the  appetite  is  to  be  improved. 

Medical  Treatment. — No  specific  drug  for  entamebic  dysentery 
has  yet  been  discovered,  though  several  remedies  have  been  employed 
in  the  treatment  of  this  condition  which  modify  the  symptoms,  shorten 
the  attacks,  and  diminish  the  frequency  of  relapses,  of  which  ipecacu- 
anha and  emetin  arc  belie\-ed  by  many  to  possess  curative  properties 
in  this  form  of  colitis.  The  author's  views  are  in  harmony  with  those 
of  Strong,  who  holds  that  entamebiasis  (amebiasis)  is  an  affection  of  the 
colon,  and  it  is  unreasonable  to  suppose  that  drugs  retain  sufficient 
potentiality  after  peissing  the  stomach  and  traversing  20  feet  of  intes- 
tine to  permanently  destroy  all  entameb^. 

The  medical  treatment  should  be  begun  with  a  liberal  dose  of 
castor  oil,  sj  to  ij  (30.0-60.0);  calomel,  gr.  iij  to  v  (0.18-0.30);  magne- 
sium or  sodium  sulphate,  5j  to  viij  (4.0-30.0);  Rochelle  salts,  5j  to 
iv  (4.0-15.0),  or  a  saline  mineral  water  for  the  purpose  of  clearing  the 
inflamed  or  ulcerated  intestines  of  scybala,  tissue  debris,  and  irritating 
discharges.  Thereafter  curative  symptomatic  or  antiseptic  or  tonic 
remedies  are  prescribed  according  to  the  indications  in  different  cases. 

In  the  beginning  of  very  acute  dysentery  catharsis  should  be  ac- 
companied or  followed  by  the  administration  of  opium  in  some  form 
to  minimize  the  patient's  suffering  and  diminish  the  frequency  and 
fluidity  of  the  movements.  Opium  is  also  a  valuable  adjunct  to  the 
treatment  in  chronic  entamebic  colitis,  for  the  purpose  of  preventing 
restlessness,  securing  sleep,  allaying  pain,  peristeilsis,  and  tenesmus, 
particularly  in  weak,  emaciated  subjects,  and  may  be  administered  by 
mouth,  hypodermically,  or  in  the  form  of  a  suppository,  alone  or  in 
conjunction  with  bismuth  or  belladonna,  hot  fomentations,  turpentine 
stupes,  and  hot  irrigations.  IMorphin,  gr.  \  (0.015),  hypodermically. 
gives  the  quickest  relief  from  all  types  of  acute  pain,  but  opium  pills, 
gr.  I  to  ^  (0.015-0.03),  are  more  effective  for  controlling  abdominal 
soreness,  peristalsis,  pain,  and  diarrhea,  because  they  soothe  and  the 
contained  resin  acts  beneficently  upon  the  irritated  gut,  but  when  colic 
or  enterospasm  are  severe  or  frequent  complications,  belladonna,  gr. 
i  to  ^  (0.015-0.03),  should  be  prescribed  independently  or  with  opium. 

When  tenesmus  is  very  severe  it  can  be  relieved  b\-  hot-water,  saline, 
oil,  or  medicated  enemata  or  irrigations,  or  by  a  3-  or  4-ounce  (90- 
120)  injection  of  starch-water,  containing  laudanum,  injxv  (i.o),  and 
belladonna,  itrx  (0.60),  or  by  the  insertion  of  a  cocoa-butter  supposi- 
tory composed  of  morphin  or  cocain,  gr.  j  (0.015),  and  belladonna,  gr. 
I  to  I  (0.008-0.15),  as  often  as  may  be  required. 

Olive  oil,  liquid  parafiin,  or  petroleum,  mineral  or  hydrocarbon  oils 
(albolin,  benzoinal,  and  neutralol,  etc.),  administered  in  5j  to  ij  (30.0- 
60.0)  or  larger  doses  once  or  twice  daily,  are  soothing  and  sometimes 
do  much  toward  relieving  the  dysenteric  symptoms. 


380  ENTAMEBIC    COLITIS,    DIARRHEA    IN 

Antiseptic  remedies,  such  as  bismuth  subnitrate,  subcarbonate, 
saHcylate,  or  subgallate,  beta-naphthol,  salol,  bcnzosol  (beta-guaiacol), 
saltpeter  or  thymol,  in  10-  to  15-gr.  (0.60-1.0)  or  larger  doses,  adminis- 
tered two  or  three  times  daily,  are  the  most  popular  remedies  of  the 
class  employed  in  the  treatment  of  dysenteric  colitis.  Acetozone, 
I  :  3000,  consumed  in  liberal  amounts,  i  to  2  quarts  (1000-2000),  as 
recommended  by  Musgrave,  is  useful,  because  the  drink  is  slightly  anti- 
septic and  tends  to  minimize  gastric  and  intestinal  fermentation. 
While  antiseptics  possess  germicidal  power  and  inhibit  or  prevent  putre- 
faction and  fermentation  to  a  certain  degree,  and  in  some  instances 
add  to  the  patient's  comfort,  they  cannot  always  be  relied  upon  to 
lessen  the  patient's  suffering  or  to  cure  his  dysentery,  because  they  are 
toxic  when  administered  in  doses  of  sufftcient  strength  to  kill  the  enta- 
mebffi  and  bacteria  participating  in  the  infection.  Bismuth  and 
thymol  preparations  are  most  frequently  prescribed  in  this  class  of 
cases,  but  the  former  sometimes  does  considerable  harm  when  given 
in  large  doses  for  a  long  time,  because  it  becomes  oxidized  and  accu- 
mulates beneath  the  edges  of  ulcers  where  it  cannot  be  washed  out,  or 
forms  large  bismuth  enteroliths  or  putty-like  masses  which  irritate  or 
block  the  intestine. 

In  the  tropics,  where  it  could  be  borne,  oil  of  turpentine,  ttij3o  to  50 
(2.0-3.3),  has  in  some  instances  given  very  good  results,  but  is  objec- 
tionable because  of  its  disagreeable  odor  and  taste,  but  it  possesses 
germicidal  powers  and  can  be  used  to  advantage  with  castor  oil  in 
cases  of  chronic  dysentery  complicated  by  scybala,  constipation,  or 
large  collections  of  jelly-like  or  stringy  mucus. 

Astringent  remedies,  administered  alone  or  in  conjunction  with 
opium,  assist  in  controlling  hemorrhage,  diminishing  the  number  of 
stools,  and  making  the  patient  more  comfortable,  but  accomplish 
nothing  toward  a  permanent  cure  of  dysentery.  Of  such  remedies  the 
author  prefers  the  salicylate  of  guaiacol,  tannalbin,  tannigen  or  tanno- 
guaiaform,  tannopin  or  tannocol,  in  doses  varying  from  5  to  10  gr. 
(0.3-0.6),  administered  three  or  four  times  daily,  according  to  indica- 
tions, or  the  following  combination: 

I^     Cupri  sulph gr.  |  (0.015)  '■> 

Pulv.  opii gr.  ^  (0.03) ; 

Massa  paraffini gr.  ij  (0.12). — M. 

Ft.  one  pill. 

Sig. — One  pill  three  times  daily  in  conjunction  with  a  milk  diet. 

Acids  minimize  alkalinity  of  the  alimentary  tract  and  thereby 
hinder  the  multiplication  of  entameba?,  and  with  this  object  in  view  the 
author  has,  with  very  good  results,  occasionally  prescribed  the  mineral 
acids,  animal  and  human  gastric  juice,  champagne,  sherry,  alcohol, 
and  sour  wines,  alone  or  in  combination  with  digestive  ferments. 

Tonics,  such  as  strychnin,  when  the  patient  is  weak  and  the  heart 
is  disturbed,  and  reliable  preparations  of  iron,  when  he  has  lost  con- 
siderable blood,  are  sometimes  serviceable,  but  should  be  discontinued 
when  disliked  or  they  interfere  with  digestion. 


MEDICAL    TKKATMEXT  38 1 

Ipecacuanha. — For  many  years  ipecac  has  outranked  other  drugs 
in  the  treatment  of  entamebic  coHtis  (dysenteny-),  and  some  prominent 
authorities  maintain  that  it  is  almost  a  specific  in  this  affection, 
while  others,  including  the  author,  hold  that  it  has  no  curative  power, 
but  is  markedly  helpful  when  employed  to  quickly  diminish  the 
number  of  stools,  bleeding,  and  tenesmus.  The  author  has  frequently 
used  this  remedy  according  to  the  plans  of  those  who  know  most  about 
it,  but  in  his  hands  it  has  proved  valuable  as  a  palliative  and  disap- 
pointing as  a  curative  measure.  In  his  cases  it  has  afforded  great 
relief  in  acute,  subacute,  and  chronic  entamebic  colitis,  and  in  some 
instances  the  dysenteric  symptom-complex  has  been  partially  or  com- 
pletely controlled  in  two  or  three  days,  and  occasionally  diarrhea,  ab- 
dominal pain,  tenesmus,  and  blood  and  mucus  in  the  stools  have  disap- 
peared for  periods  \arying  from  a  few  days  to  several  weeks;  but  re- 
lapses have  sooner  or  later  occurred  in  ever\'  case,  except  when  the 
ipecac  treatment  was  reinforced  by  intestinal  irrigation  or  tropical 
applications.  In  some  of  the  author's  cases  the  number  of  motile 
entamebic  in  the  dejecta  were  apparently  diminished  by  the  administra- 
tion of  ipecac,  but  in  every  case  they  were  found  in  the  stools  later, 
following  repeated  examinations  of  the  dejecta. 

Authorities  differ  widely  as  to  the  modus  operandi  of  ipecacuanha, 
but  no  one  really  knows  how  its  beneficent  action  is  brought  about,  for 
this  may  be  accomplished  by  (a)  the  direct  action  of  the  drug  which 
attenuates  or  kills  the  entamebse;  {b)  changes  caused  in  the  intestinal 
content  which  discourages  multiplication  of  the  parasites;  (c)  its  sooth- 
ing effect  upon  the  inflamed  or  ulcerated  bowel  or  in  some  other  way. 
It  is  known  that  this  remedy,  when  administered  in  small  and  re- 
peated doses,  acts  as  a  tonic  to  the  mucosa,  but  this  would  not  account 
for  the  manner  in  which  the  drug  diminishes  the  stools,  minimizes 
bleeding,  and  lessens  tenesmus.  When  it  is  known  to  be  effective  in 
a  given  case,  the  dysenteric  symptom-complex  is  urgent,  and  until 
results  are  not  obtainable  from  dieting,  intestinal  irrigation,  and  other 
therapeutic  measures  one  is  justified  in  employing  ipecac,  but  under 
other  circumstances  it  is  to  be  discountenanced  because  the  drug  is 
difficult  to  administer,  causes  distressing  nausea,  vomiting  or  saliva- 
tion, disturbs  digestion,  and  in  other  ways  interferes  with  the  body 
functions. 

Usually  ipecacuanha  is  contra-indicated  in  very  acute  dysentery 
in  anemic,  weak,  and  emaciated  patients,  pregnant  women,  those  who 
have  severe  heart  trouble,  vomit  easily,  and  in  children  and  persons 
severely  ill  from  other  affections.  Authorities  differ  greatly  as  to  the 
manner  of  administering  and  the  dosage  of  ipecacuanha,  but  this  is  not 
strange,  since  it  cannot  be  given  advantageously  in  a  routine  way  be- 
cause of  the  variations  encountered  in  different  cases. 

To  obtain  the  best  results  it  is  advisable  to  put  the  patient  in  bed, 
keep  him  on  a  milk  diet  or  fast  a  few  hours,  and  clear  the  bowel  with 
Epsom  or  Glauber's  salts,  castor  oil,  or  calomel  prior  to  administration 
of  the  drug.     In  the  beginning  only  moderate  or  large  doses  are  effect- 


382  ENTAMEBIC    COLITIS,    DIARRHEA    IN 

ive,  but  later,  as  the  diarrhea,  abdominal  pain,  tenesmus,  and  mucus 
and  blood  in  the  stools  lessen,  the  dose  should  be  gradually  diminished. 
Naturally,  the  amount  prescribed  is  not  so  great  in  moderate  as  in 
severe  cases,  when  the  author  administers  45  gr.  (3  gm.)  the  first  night 
and  thereafter  diminishes  the  amount  3  gr.  (0.18  gm.)  daily  until  10 
gr.  (0.60  gm.)  is  reeiched,  a  dose  which  is  continued  daily  one  or  several 
weeks  until  the  dysenteric  manifestations  are  modified,  cease,  or  the 
patient  cannot  longer  take  the  drug  on  account  of  nausea  and  vomiting. 
Better  results  are  obtained  when  the  patient  abstains  from  eating  for 
a  time  after  taking  the  drug,  and  limits  the  amount  of  solid  food  con- 
sumed during  this  part  of  the  treatment. 

In  urgent  cases  two  doses  may  be  administered  daily,  and  in  mild 
ones  one  every  other  day  will  suffice.  Ipecac  in  its  natural  state  is  diffi- 
cult to  administer,  causes  nausea  and  vomiting,  and  is  often  expelled 
from  the  stomach  before  it  has  accomplished  any  good,  and  because  of 
this,  and  to  avoid  the  necessity  of  giving  an  opiate  to  quiet  the  stomach, 
the  author  has  been  accustomed  to  administer  it  in  kreatinized  choco- 
late, salol-covered  pills  or  in  gelatin  capsules.  Nausea  and  vomiting  can 
often  be  prevented  or  minimized  by  keeping  the  patient  quiet  in  a 
darkened  room,  with  head  lowered,  restricting  the  diet,  and  applying 
an  ice-bag  or  mustard  plaster  over  the  stomach. 

Regarding  the  effects  of  ipecac  the  author's  observations  agree 
with  those  of  Brown,  who  says,  "In  most  instances  a  copious  loose 
motion  of  characteristic  yellow  color  and  acid  reaction  is  passed  within 
three  or  four  hours,  and  the  patient  experiences  a  marked  sense  of 
relief.  Similar  discharges,  almost  entirely  free  from  mucus  and 
blood,  are  voided  during  the  next  two  or  three  days,  the  intestinal 
functions  gradually  become  normal,  and  the  patient  is  soon  convales- 
cent." 

Emetin,  the  chief  alkaloidal  product  of  ipecac,  first  shown  by 
Vedder  to  be  very  effective  in  entamebiasis,  seldom  if  ever  causes 
nausea  or  vomiting.  Entamebee  which  come  in  contact  with  it  in  the 
bowel  and  those  placed  in  high  dilutions  of  emetin  appear  to  die  at 
once,  and  recent  experiments  with  the  drug  indicate  that  it  is  almost 
if  not  a  specific  in  entamebic  dysentery. 

Emetin  relieves  the  dysenteric  symptom-complex  {diarrhea,  abdomi- 
nal pain,  blood,  mucus  and  pus  in  the  stools,  and  tenesmus)  almost  imme- 
diately without  causing  other  manifestations  irrespective  of  the  dura- 
tion of  the  disease  or  virulence  of  its  symptoms.  Emetin  acts  quickly, 
is  more  effective,  and  is  more  acceptable  to  patients  than  ipecac.  Fol- 
lowing its  administration  diarrhea  frequently  ceases  within  a  week, 
pus,  blood,  mucus,  and  entamebae  temporarily  or  permanently  disap- 
pear from  the  evacuations,  and  the  patient  rapidly  gains  in  weight. 

Rogers  has  shown  that  emetin  does  not  improve  bacillary  colitis, 
hence  in  suspected  cases  of  dysentery,  where  the  patient's  condition 
rapidly  improves  following  its  administration,  one  is  justified  in  infer- 
ring that  the  infection  is  due  to  entamebae.  The  emetin  salts — 
hydrochlorid  and  hydrobromid — are  employed  in  a  solution  which  is 


LOCAL    TREATMENT  383 

injected  beneath  the  skin  two  or  more  times  daily,  according  to  the 
exigencies  of  the  case.  Beginning  with  g  gr.  (6.01),  the  dose  is  in- 
creased to  ^  or  I  gr.  (0.02-0.03),  and  is  continued  every  few  hours  until 
from  I  to  1 5  gr.  (0.06-0.09),  which  equals  from  90  to  130  gr.  (6.0-8.60) 
of  ipecac,  have  been  taken.  Reported  cases  indicate  that  this  amount 
of  emetin  is  usually  effective  in  obstinate  cases  of  dysentery.  The 
author  has  had  a  limited  and  fairly  satisfactory  experience  with  the 
remedy,  but  would  advise  that  the  drug  be  continued  in  small  doses 
for  a  few  weeks  after  an  apparent  cure  to  forestall  a  possible  relapse. 

Local  Treatment. — Rest,  regulating  the  diet,  and  internal  admin- 
istration of  medicine  are  helpful,  but  alone  or  combined  they  are  not 
nearly  so  valuable  in  the  treatment  of  entamebic  colitis  (dysentery)  as 
IRRIGATIONS  and  TOPICAL  APPLICATIONS  which  come  unchanged  into 
direct  contact  with  the  inflamed  and  ulcerated  mucosa.  Many  times 
the  author  has  succeeded  in  curing  patients  by  thorough  irrigation  who 
prexiously  had  been  treated  for  a  long  time  with  other  therapeutic 
measures  without  benefit.  Medicated  irrigation  is  effective  because 
it  insures  drainage  of  the  polluted  bowel  and  dislodges,  washes  out, 
attenuates,  or  destroys  entameba?,  colon  bacilli,  streptococci,  and  other 
pathogenic  micro-organisms  which  participate  in  specific  and  later  in 
mixed  infection,  which  follows  denudation  of  the  mucous  membrane. 
This  treatment,  to  be  effective,  must  be  employed  suf^ciently  often  to 
keep  the  intestine  free  from  irritating  discharges,  debris,  and  feces,  and 
to  accomplish  this  copious  irrigations  are  required  and  the  position 
of  the  patient  must  be  changed  from  time  to  time  during  the  washing 
out,  so  that  the  fluid  is  made  to  come  in  contact  with  every  portion  of 
the  infected  mucosa  throughout  the  colon  and  rectum.  This  irrigat- 
ing treatment  frequently  fails  because  the  amount  of  solution  used 
is  too  small  or  does  not  reach  sufficiently  high,  or  the  lavage  is  always 
carried  out  with  the  patient  in  the  same  position,  which  permits  the 
medicated  fluid  to  traverse  one  side  of  the  bowel  only  and  keeps  it 
from  coming  in  contact  with  the  lesions  on  the  other  side. 

The  beneficent  action  of  bowel  washing  in  these  cases  is  due  more 
to  the  mechanic  action  of  the  fluid  in  cleansing  the  ulcers  and  inflamed 
gut  of  irritating  material  than  to  its  temperature  (extreme  heat  or 
cold)  or  the  contained  drugs. 

Patients  who  have  not  been  benefited  by  other  therapeutic  measures 
immediately  gain  courage  upon  institution  of  the  irrigating  treatment 
because  it  brings  about  immediate  partial  or  complete  relief,  and  they 
feel  as  if  the  seat  of  their  trouble  htis  finally  been  located  and  is  being 
treated.  Enemata  are  preferable  to  no  treatment,  but  continuous 
irrigation,  according  to  the  plans  described  below,  are  far  superior  to 
them.  Frequently  in  acute  and  practically  always  in  chronic  entamebic 
colitis  the  bowel  is  highly  inflamed  and  extensively  ulcerated,  and  in 
consequence  the  injection  and  retention  of  a  sufficient  amount  of 
water  or  a  medicated  solution  to  reach  all  parts  of  the  infected  colon 
may  induce  considerable  pain,  coloptosis,  or  result  in  perforation  of  the 
intestine  and  peritonitis;  hence  the  importance  of  being  careful  when 


384  ENTAMEBIC    COLITIS,    DIARRHEA    IN 

administering  large  enemata  of  from  2  to  4  quarts  (liters).  When  it 
is  desirable  to  have  the  solution  retained  for  a  time  this  can  be  accom- 
plished by  inserting  a  self-retaining  anal  dilator,  through  the  center 
of  which  runs  a  tube  which  can  be  clamped  when  the  desired  amount  of 
fluid  has  been  introduced.  The  injection  may  be  permitted  to  flow 
out  gently  through  the  pipe  when  necessary,  or  be  encouraged  to 
come  away  at  once  by  placing  the  patient  upon  a  commode  and  re- 
moving the  dilator. 

About  the  only  time  the  author  resorts  to  large  and  retained  ene- 
mata is  when  he  has  reasons  to  believe  that  the  ileum  is  also  infected. 
Unique  past  experiences  in  the  treatment  of  specific  and  other  forms 
of  inflammatory  and  ulcerative  lesions  of  the  small  intestine,  together 
with  photographs  (see  Fig.  131)  of  the  small  and  large  bowel,  taken  by 
means  of  the  bismuth  injection  x-ray  process,  has  convinced  the  author 
that  occasionally  if  not  frequently  solutions  under  reasonable  pressure 
can  be  made  to  pass  along  the  colon  through  the  ileocecal  valve  into 
the  ileum.  Cole,  the  Xew  York  rontgenologist,  has  taken  a  number  of 
pictures  for  the  author  which  plainly  show  that  the  bismuth  injection 
often  reaches  the  small  gut  when  given  as  an  ordinary  injection  with- 
out extra  pressure,  and  this  does  not  imply  an  incontinence  of  the 
ileocecal  valve. 

Irrigations  and  enemata  should  preferably  be  given  at  the  body 
temperature  or  slightly  warmer,  for  then  they  are  soothing  and  induce 
the  least  discomfort,  but  in  the  presence  of  cramps  the  solution  may  be 
employed  as  hot  as  110°  F.,  because  at  this  temperature  it  relieves 
pain  and  causes  relaxation  of  the  intestinal  musculature.  Ice-cold 
irrigations  attenuate  entamebse  in  the  bowel  and  beneath  the  mucosa, 
but  they  frequently  cause  considerable  pain,  enterospasm,  and  a 
desire  for  their  expulsion  before  they  have  accomplished  their  purpose, 
and,  so  far  as  the  author  has  been  able  to  observe,  they  do  not  per- 
manjently  destroy  entamebce.  Formerly  it  w^as  believed  that  long  tubes 
were  necessar>'  for  complete  colonic  flushing,  but  recently  the  author 
has  confirmed  Hanes'  findings  (see  Fig.  127),  that  in  nearly  all  cases  it 
is  impossible  to  introduce  the  tube  beyond  the  middle  sigmoid  flexure. 
Enemata  and  irrigations  can  be  made  to  reach  all  parts  of  the  large 
bowel  by  pouring  them  through  a  proctoscope  into  the  sigmoid  flexure 
while  the  subject  is  in  the  inverted  posture,  by  using  the  author's 
funnel-shaped  proctoscope  and  pitcher  (see  Fig.  124),  or  permitting  the 
solution  to  flow  into  the  rectum  through  a  short,  soft,  hard-rubber,  or 
metal  tube  while  the  patient  remains  in  the  Sims  or  lithotomy  position 
with  the  hips  well  elevated.  When  the  fluid  does  not  pass  rapidly  or 
high  enough  it  can  be  made  to  do  so  by  elevating  the  irrigating  con- 
tainer, straightening  out  kinks  in  the  tube,  changing  the  patient's 
position,  or  by  massaging  the  colon  in  an  upward  direction. 

Frequently  patients  complain  of  severe  abdominal  pain  following 
injections  and  irrigations,  and  this  can  be  avoided,  when  it  is  not  due 
to  ulcers  or  distention,  by  holding  the  irrigating  nozzle  upward  and 
letting  the  fluid  run  through  it  until  all  air  is  out  of  the  tube  before  it  is 


LOCAL    TREATMENT  385 

introduced.  When  this  precaution  heis  not  been  taken,  usually  the 
intense  suffering  of  the  patient  can  be  promptly  relieved  by  introducing 
a  proctoscope  or  rubber  tube  and  permitting  the  air  and  gas  to  escape. 

When  the  bowel  is  particularly  sensitive,  it  is  occasionally  advisable 
to  precede  the  washing  out  by  the  administration  of  an  opiate  inter- 
nally or  in  the  form  of  a  suppository,  and  when  enterospasm  is  a  com- 
plication, belladonna  should  be  used  in  conjunction  with  it. 

In  chronic  dysentery  the  bowel  should  be  irrigated  once  or  twice 
daily,  according  to  indications,  for  several  weeks  or  uKMiths  or  until 
entamebae  disappear  from  the  stools  and  the  patient  has  apparently 
been  cured,  because  these  specific  organisms  are  to  be  found  free  in  the 
bowel  and  embedded  beneath  the  mucosa,  and  frequent  and  prolonged 
flushing  is  imperatix'e  if  the  intestine  is  to  be  permanently  freed  of 
them. 

Critically  ill  and  extremely  weak  patients  should  be  required  to  rest 
quietly  in  bed  during  and  following  irrigation,  but  fairly  strong  indi- 
viduals may  be  permitted  to  exercise  in  the  open  air  or  attend  to  their 
work  following  the  treatment. 

When  there  is  reason  for  believing  that  the  rectum  contains  scybala 
or  softened  feces,  a  small  soapsuds  or  saline  enema  should  be  ad- 
ministered to  cleanse  the  intestine  before  it  is  irrigated,  and  much 
better  results  are  obtained  if,  when  the  bowel  contains  considerable  gas, 
it  is  permitted  to  escape  through  a  tube  or  proctoscope  before  the 
treatment  is  begun. 

The  flow  of  the  solution  is  less  apt  to  be  interrupted  by  intestinal 
contractions  when  it  is  allowed  to  run  in  rapidly  than  when  it  is 
permitted  to  trickle  in ;  and  the  inflow  must  be  regulated  to  meet  the 
indications  in  different  cases.  Under  all  circumstances  it  is  well  to 
bear  in  mind  that  the  tolerance  of  individuals  to  enemata  and  irriga- 
tions varies  greatly,  and  that  one  can  stand  the  introduction  of  a 
greater  amount  of  solution  than  another. 

The  best  results  are  obtainable  with  a  minimum  disturbance  to  the 
patient  and  the  least  inconvenience  to  doctor  or  nurse  when  the  intes- 
tine is  irrigated  by  means  of  a  Gant  (see  Fig.  158)  or  Kemp  irrigator 
or  a  return  flow  colonic  tube  of  the  J  elks  or  Murray  (see  Fig.  120) 
types,  and  more  particularly  when  from  3  to  10  quarts  (liters)  of  the 
solution  are  used  in  the  process. 

Occasionally,  where  the  bowel  is  extensively  ulcerated  and  it  is 
desirable  to  obtain  a  prolonged  application  of  the  medication  to  the 
ulcers,  it  is  advisable  to  block  the  anus  and  temi)<)rarily  retain  part  of 
the  solution,  but  in  most  instances  the  treatment  is  most  effective  when 
the  fluid  is  permitted  to  flow  directly  through  and  out  of  the  bowel,  if 
during  which  time  {jrecautions  are  taken  to  see  that  it  reaches  all  parts 
of  the  infected  gut. 

When  administering  enemata  or  irrigations  no  attempt  should  be 
made  to  force  the  proctoscope,  sigmoidoscope,  irrigator,  or  colon  tube 
upward  when  its  progress  has  been  arrested,  because  the  bowel  may  be 
perforated,  the  patient  is  made  to  suffer  unnecessary  pain,  and   the 

25 


386  ENTAMEBIC    COLITIS,    DIARRHEA    IN 

treatment  will  fail,  since  kinking  of  the  tube  prevents  the  upward  flow 
of  the  solution.  Sometimes  this  trouble  can  be  overcome  by  withdraw- 
ing and  reintroducing  the  tube  and  letting  the  fluid  run  rapidly,  partic- 
ularly when  the  opening  is  in  the  end  and  not  at  the  side  of  the  pipe. 
For  further  information  relative  to  the  technic  of  irrigating  the  colon 
and  administering  enemata  the  reader  is  referred  to  Chapter  XLI. 

Irrigants. — Water,  saline,  disinfecting,  astringent,  antiseptic,  and 
specific  (so-called)  solutions  of  various  kinds  have  been  employed 
in  entamebic  and  other  types  of  dysenteric  colitis,  with  the  idea  of 
dislodging,  weishing  out,  attenuating,  or  killing  entamebse  and  other 
pathogenic  organisms  within  the  bowel,  reducing  inflammation,  healing 
ulcers,  lessening  toxemia,  removing  debris  and  discharges,  relieving 
pain,  colic  and  enterospasm,  and  stimulating  the  local  and  general 
circulation,  but  many  of  those  recommended  are  unsuitable  because 
they  are  not  effective,  irritate  the  bowel,  or  cause  shock. 

Of  the  solutions  which  have  been  successfully  employed  in  the  treat- 
ment of  entamebic  colitis,  the  following,  named  in  the  order  of  their 
usefulness,  have  given  the  best  results — viz.,  silver  nitrate,  ichthyol, 
thymol,  potassium  permanganate,  protargol,  argyrol  and  acetozone, 
I  :  I  GOO  to  2000,  and  J  elks'  formalin  combination  given  below.  These 
agents  are  germicidal  to  a  certain  extent,  effectively  cleanse  the  bowel, 
and  encourage  healing.  When  diarrhea  is  marked,  bleeding  is  profuse, 
and  the  discharges  are  abundant  the  strength  of  the  solution  should  be 
increased  and  afterward  diminished  as  the  condition  of  the  patient 
improves.  Ichthyol  (2  to  5  per  cent.)  is  the  most  desirable  drug  to 
employ  when  the  stools  are  particularly  ofTensive,  and  a  solution  of  hy- 
drogen peroxid  (10  per  cent.)  is  also  useful  here  because  of  its  soothing, 
antiseptic,  and  deodorizing  action,  and  an  irrigation  of  iodin  {\  to  i 
per  cent.)  may  be  employed  for  the  same  purpose,  but  is  more  irritating 
to  the  mucosa. 

The  bisulphate  and  other  salts  of  quinin  are  thought  by  some  to 
possess  a  specific  action  against  entamebse  (amebae),  but  the  author's 
experience  with  the  drug  does  not  indicate  that  this  is  so,  and  he  be- 
lieves that  the  chief  benefit  derived  from  quinin  solutions  are  due  to 
their  cleansing  and  healing  powers. 

The  silver  preparations  should  be  employed  very  strong  when 
beginning  the  treatment,  and  in  cases  where  the  gut  is  extensively 
ulcerated  the  author  frequently  injects  i  quart  (liter)  of  water  con- 
taining 30  gr.  (2.0)  of  silver  nitrate,  and  then  as  improvement  follows 
reduces  the  amount  5  gr.  (0.30)  each  day  until  10  gr.  (0.60)  is  reached, 
and  continued  until  a  more  soothing  irrigant  will  sufUce.  Silver  in 
the  above  strength  causes  a  drawing  or  puckering  sensation  in  the 
bowel,  but  seldom  induces  sharp  pain,  but  when  it  does,  this  can  be 
relieved  by  flushing  the  bowel  with  a  warm  normal  saline  solution. 
Argyrol  and  protargol  are  useful,  but  are  rarely  employed  because  of 
their  cost.  Acetozone  and  alphozone,  when  made  up  in  an  acid  solu- 
tion, possess  decided  germicidal  powers,  but  are  objectionable,  owing 
to  their  irritating  properties.     The  author  has  successfully  employed 


IRRIGANTS  387 

Jclks'  formalin  boric  solution,  with  which  he  has  obtained  satisfactory 
results.  This  irrigant  is  composed  of  i  :  300  or  400  of  the  formahn 
solution  (which  makes  approximately  a  I  :  looo  solution  of  formaldehyd 
gas),  to  which  he  adds  a  tablespoonful  of  boric  acid  for  each  quart 
(liter).  Jelks  has  also  employed  copper  phenol-sulphate  in  conjunction 
with  the  formalin  solution  because  of  its  parasitic  and  astringent 
qualities,  and  claims  that  the  formalin-boric  acid  solution  is  effective 
because  it  kills  or  inhibits  entamebee,  Paramecium,  and  colon  bacilli, 
the  formaldehyd  gas  is  absorbed,  permeates  the  infected  foci,  and  de- 
stroys symbiotic  bodies,  which  discourages  the  production  of  entamebse. 

Quite  often  it  is  advisable  to  alternate  soothing  with  the  antiseptic, 
astringent,  or  stimulating  remedies  just  discussed,  because  the  latter 
irritates  the  intestine  and  favors  extension  of  more  than  minimization 
of  the  infection,  and  occasionally  the  author  has  been  compelled  to  dis- 
continue the  usual  irrigations  and  substitute  a  methylene-blue  solution, 
oils,  emulsions,  etc.,  for  them,  which  have  a  sedative  action  upon  the 
mucosa  and  lead  to  an  improvement  in  the  patient's  condition  because 
of  their  tendency  to  quiet  intestinal  activity. 

The  favored  soothing  remedies  employed  by  the  author,  named 
in  the  order  of  their  usefulness,  are  crude  petroleum,  coal  oil  (refined 
petroleum),  liquid  parafifin,  so-called  mineral  (petroleum),  olive  and 
sweet  almond  oils,  alone  or  in  combination  with  bismuth,  thymol, 
orthoform,  iodoform  or  other  sedative,  astringent  or  antiseptic  drug, 
starch,  oatmeal  or  flaxseed  tea,  slippery  elm  and  boric  acid  solutions, 
all  of  which  are  more  effective  when  used  hot.  The  following  emulsion, 
with  slight  variations,  has  been  used  by  the  author  with  universal 
success  for  years  to  reduce  inflammation,  heal  ulcers,  minimize  tenes- 
mus, and  quiet  pain  in  the  large  intestine,  and  may  be  injected  directly 
into  the  rectum  or  through  a  colostomy,  appendicostomy,  or  cecostomy 
opening. 

I^    Olive  oil Oj  (500.0); 

Orthoform 5  j-ij  (4-8) ; 

Bismuth  sub.  nit 5  j  (30-0). — M. 

Sig. — Shake,  warm,  and  inject  3  ounces  or  more  into  the  bowel  and  permit  it  to 
remain  over  night. 

One  inexperienced  with  the  formula  would  expect  it  to  be  expelled 
in  short  order,  but  this  never  occurs  when  the  emulsion  is  deposited 
in  the  sigmoid  or  higher,  because  it  is  frequently  retained  for  twenty- 
four  hours  or  longer  and  reduces  irritation,  arrests  peristalsis,  lessens 
diarrhea,  and  diminishes  tenesmus  and  pain. 

The  author  cannot  refrain  from  commending  the  coal-oil  treatment 
of  Hanes,  because  it  is  one  of  the  best  remedies  we  possess  for  relieving 
and  curing  entamebic  dysentery  and  for  healing  other  inflammatory 
and  ulcerative  lesions  of  the  colon.  It  accomplishes  the  desired  results 
owing  to  its  remarkable  parasiticidal,  sedative,  and  healing  properties, 
and  because  it  is  absorbable,  non-irritating,  and  is  retained  for  a  con- 
siderable time.     The  best  results  are  derived  from  coal  oil  when  it  is 


388  ENTAMEBIC    COLITIS,    DIARRHEA    IX 

warmed  and  injected  in  liberal  amounts— i  quart  (liter)  or  more — 
through  a  proctoscope  introduced  after  the  bowel  has  been  cleansed  and 
the  patient  placed  in  the  inverted  posture  (see  Fig.  122),  which  favors 
the  displacement  of  adjacent  organs  and  intestinal  loops,  escape  of  the 
intestinal  gases,  and  the  tra\"ersing  of  the  entire  colon  by  the  oil.  The 
treatment  is  still  more  eflfective  when  administered  just  before  going  to 
bed.  or  by  having  the  patient  lie  down  for  a  few  minutes  following  its 
introduction  when  he  is  to  be  active  later.  The  author  has  many  times 
demonstrated  that  one  or  several  quarts  of  coal  oil  can  be  projected 
into  the  bowel  without  causing  pain  or  toxic  manifestations.  In  fact, 
patients  almost  invariably  feel  better  following  the  treatment. 

Laudanum,  iri.kx  (1.3),  or  an  opiate  in  some  form  may  be  added 
with  advantage  to  starch-  or  rice-water  or  other  injections  when  the 
patient  has  an  extremely  sensitive  bowel  and  suffers  intensely  from  pain 
and  tenesmus. 

The  symptoms  of  entamebic  colitis  can  often  be  modified  or  a  cure 
effected  more  quickly  when  dieting,  medication,  and  irrigation  are  re- 
inforced by  topical  applications  made  to  ulcers  and  the  inflamed  mucosa. 
Through  the  proctoscope  and  sigynoidoscope  one  can  readily  locate 
and  treat  lesions  requiring  special  attention,  and  apply  remedies  to  the 
bowel  upward  to  the  middle  sigmoid,  which  assist  in  healing  the  ulcers 
and  reducing  intestinal  irritability,  pain,  tenesmus,  and  diarrhea. 
Usually  one  treatment  daily  is  sufticient,  and  not  more  than  two  should 
ever  be  made,  because  frequent  instrumentation  may  do  more  harm 
than  good,  particularly  when  it  is  done  ignorantly  or  carelessly. 
Spraying  the  bowel  with  oil  and  alkaline  soothing,  antiseptic,  and 
astringent  preparations  similar  to  the  composition  of  those  employed 
in  the  treatment  of  throat  troubles  affords  considerable  relief  in  the 
presence  of  acute  and  chronic  sigmoidoproctitis  and  when  there  are 
erosions  in  the  mucous  membrane.  Insufflation  of  the  rectum  with 
boric  acid,  antiseptic,  astringent,  or  Rosenberg's  powder,  or  the  au- 
thor's formula  are  useful  in  the  same  class  of  cases,  viz.: 

I^     Acidi  tannici gss  (15.0); 

]\Iagnesium 5  ^iss  (loo.o) ; 

01.  thymi 5j  (4-o). — M. 

{Rosenberg.) 

I^     Talcum  pulv 5  ij  (8.0) ; 

Hydrarg.  chlor.  mit oj  (4-°); 

Zinci  stearati  I  __  , —  to    \      -mt 

Acidi  tannici  .■   ^^  OiJ  (S.o).-M. 

Sig. — Insufflate  through  the  sigmoidoscope.  '{Gant.) 

Prior  to  the  making  of  topical  applications,  ulcers  should  be  iso- 
lated after  the  bowel  has  first  been  cleansed  of  discharges  and  feces  by 
wiping  or  flushing  it. 

Extensi\"e  and  long-standing  ulcers  whicli  do  not  respond  to 
milder  measures  should  be  cauterized  with  the  electric  or  Paquelin 
cauter\-  or  chemical  agents,  the  most  reliable  and  safest  of  which  are 


SURGICAL  tri:atment  389 

silver  nitrate  or  copper  sulphate  (50  per  cent.)  and  pure  ichthyol  or  the 
balsam  of  Peru.  When  ulcers  are  numerous  and  of  recent  origin,  they 
can  be  made  to  heal  quickly  by  painting  them  three  times  weekly 
with  a  solution  of  silver  nitrate,  10  lo  15  percent.;  ichthyol,  25  to  50 
per  cent.;  balsam  of  Peru,  50  per  cent.;  protargol  or  argyrol,  20  per 
cent.,  and  then  irrigate  the  bowel  on  alternate  days. 

Frequently  dysenteric  and  other  lesions  of  the  rectum  are  extremely 
irritable,  and  the  application  of  the  above  stimulating  drugs  aggravates 
them,  under  which  circumstances  they  should  be  discontinued  for 
soothing  remedies,  the  most  universally  successful  of  which  are 
methylene-blue,  10  per  cent.,  and  emulsions  composed  of  oil,  Oj  (500.0), 
which  is  soothing,  bismuth  subnitrate,  5ss  (15.0),  which  covers  and 
protects  the  lesions,  and  analgen  or  orthoform,  3j  (4.0),  which  minimize 
intestinal  irritability  and  pain.  In  making  topical  applications  it  is 
advisable  to  treat  the  highest  ulcer  first  and  then  gradually  work  down- 
ward toward  the  anus. 

Dysenteric  ulcers  are  always  most  numerous  and  large  in  the  lower 
sigmoid  and  rectum,  and  since  they  usually  respond  readily  to  local 
treatment  the  importance  of  topical  applications  in  this  class  of  cases 
is  apparent. 

Treatments  made  to  lesions  at  or  near  the  anus  cause  considerable 
pain,  and  sometimes  the  upper  rectum  is  very  sensitive;  consequently, 
when  necessary,  it  is  advisable  to  spray  the  ulcers  with  or  apply  a  10 
per  cent,  cocain  or  eucain  solution  to  them  before  the  treatments  are 
made.  Care  should  be  used  to  limit  the  caustic  applications  to  the 
lesions,  because  when  they  cover  large  areas  of  the  mucosa  dangerous 
or  fatal  poisoning  or  sloughing  of  the  mucosa  may  ensue. 

Surgical  Treatment. — Entamebic  colitis  becomes  a  surgical  dis- 
ease immediately  in  acute  cases  where  the  patient  is  profoundly  poi- 
soned, loses  a  dangerous  amount  of  blood,  or  suffers  incessantly  from 
diarrhea  and  it  is  obvious  that  other  measures  will  not  bring  prompt 
relief,  and  in  subacute  and  chronic  cases,  where  he  does  not  respond  to 
rest,  dieting,  internal  medication,  and  irrigation  from  below.  The 
author  has  had  a  large  experience  in  the  treatment  of  all  forms  of  dys- 
enteric colitis  and  with  the  various  surgical  procedures  employed  for 
the  purpose,  and  his  experience  warrants  the  opinion  that  surgery  is 
the  most  reliable  therapeutic  measure  suggested  for  the  cure  of  this 
affection  in  the  vast  majority  if  not  in  all  cases.  Since  drainage  is  the 
essential  feature  in  the  treatment  of  entamebic  colitis,  is  it  not  reason- 
able to  maintain  that  operations  which  provide  a  means  of  through- 
and-through  irrigation  will  shorten  the  convalescence  in  all  instances 
and  frec|uently  effect  a  permanent  cure  when  other  measures  have  been 
faithfully  tried  or  failed? 

Since  the  appendix  and  cecum  frequently,  if  not  always,  contain 
nests  of  entameba',  it  is  obvious  that  these  regions  must  be  reached 
by  the  irrigant,  and  the  specific  organisms  free  in  the  bowel  and 
embedded  in  the  submucosa  destroyed  and  re-infection  of  the  gut 
below  prevented. 


390  ENTAMEBIC    COLITIS,    DIARRHEA    IX 

The  author  first  attempts  to  accomplish  this  by  irrigation,  carried 
out  by  way  of  the  attus.  and  frequent  changes  in  the  patient's  posture; 
but.  when  for  any  reason,  all  of  the  infected  areas  are  not  reached 
by  the  solution,  the  patient  fails  to  improve,  and  suffers  frequently 
from  relapses,  he  promptly  operates  and  makes  an  i)ilet  (appendicos- 
tomy  or  cecostomy)  at  the  head  of  the  colon,  so  that  it  can  be  fre- 
quently and  thoroughly  cleansed  from  one  end  to  the  other,  and,  in 
addition,  appendectomy  is  performed  when  indicated.  The  author 
has  never  failed  to  benefit  dysenteric  colitis  by  operation,  but  in  four 
or  five  instances  patients  have  had  relapses  extending  over  a  period 
of  from  three  months  to  tv\-o  years  before  they  were  cured,  and  in  one 
instance  the  operation  (appendicostomy)  utterly  failed.  In  these 
cases,  where  the  surgical  treatment  proved  unsatisfactory,  the  enta- 
mebic  infection  extended  well  into  the  ileum  (supposedly  from  the 
symptoms  and  cures  which  subsequently  followed  the  author's  entero- 
cecostomy) ,  or  was  complicated  by  balantidic  or  helminthic  infection  or 
some  other  debilitating  disease. 

Naturally,  patients  who  are  operated  upon  when  they  are  extremely 
weak  and  emaciated,  and  whose  digestive  organs  are  greatly  impaired, 
convalesce  ver\-  much  slower  than  persons  who  ha^"e  been  ill  only  a 
short  time  and  are  comparatively  robust.  The  establishment  of  an 
artificial  inlet  in  the  upper  colon  is  of  the  greatest  importance  to  the 
patient,  both  because  the  treatment  rapidly  improves  his  condition 
and  he  is  independent  of  doctor  and  nurse,  since  he  can  effectively 
irrigate  the  bowel  thereafter  without  their  assistance. 

Operations  of  this  class  immediately  influence  the  bowel  in  some 
way  (probably  through  the  mind),  for  ven."  often  the  diarrhea  is 
greatly  improved  before  flushing  is  begun.  Following  appetidicostomy, 
the  author's  enterocecostomy.  and  cecostomy  the  number  of  evacuations 
become  rapidly  fewer,  and  the  manifestations  of  toxemia  begin  to  im- 
prove as  soon  as  through-and-through  irrigation  is  instituted.  In  aggra- 
vated cases  the  number  of  evacuations  (twenty  to  thirty  daily)  are 
lessened  by  one-half,  and  the  amount  of  pus  and  blood  passed  are  ver>' 
greatly  decreased  by  the  first  week,  and  not  infrequently  at  the  end  of 
the  second  abdominal  pain  and  tenesmus  cease,  there  is  a  slight  amount 
of  blood  and  pus  in  the  dejecta,  and  the  patient  does  not  have  more 
than  two  or  three  movements  daily.  Usually  the  diarrhea  is  cured 
and  entamebae  completely  disappear  from  the  stools  within  a  month 
or  six  weeks;  but  since  relapses  have  occurred  when  the  artificial  open- 
ings were  closed  too  soon,  the  author  now  leaves  them  open  for  at  least 
six  months,  and  all  the  time  when  the  patient  lives  in  tropical 
countries  where  entamebic  colitis  is  endemic. 

As  a  rule,  when  marked  improvement  does  not  follow  appendicos- 
tomy or  cecostomy  and  through-and-through  irrigation,  it  is  because  all 
sides  of  the  bowel  are  not  reached  by  the  fluid,  the  disease  extends  to 
the  small  gut.  digestion  is  impaired,  tuberculosis  of  the  lung  or  bowel 
is  a  complication,  or  the  entamebic  is  aggravated  by  balantidic,  hel- 
minthic, or  other  specific  infection  or  disease  which  delays  healing  of 


SURGICAL    TRRATMEXT  39 1 

the  bowel  or  depletes  the  p^itient's  health.  Under  such  circumstances 
the  position  of  the  patient  should  be  frequently  changed  during  the 
flushing,  or  the  local  treatment  should  be  reinforced  by  therapeutic 
measures  which  will  correct  the  associated  ailments. 

To  a  certain  extent  these  operations  improve  the  diarrheic  condi- 
tion by  the  arrest  of  peristalsis  through  the  cecal  suspension.  Appen- 
dicostomy,  cecostomy,  and  bowel-washing  improve  but  do  not  cure 
patients  where  the  intestine  has  been  extensively  involved  by  slough- 
ing or  ulceration  which  has  resulted  in  partial  or  complete  stricture  at 
one  or  more  points,  for  in  the  presence  of  stenoses,  diarrhea,  pus  and 
blood  in  the  stools,  and  straining  continue. 

When  establishing  an  artificial  opening  to  provide  for  drainage, 
except  when  the  appendix  is  used,  appendectomy  is  advisable,  for  when 
the  organ  contains  entamebcC  and  is  not  removed  reinfection  from  this 
source  is  sure  to  follow. 

Cecostomy  and  appendicostomy  are  practically  devoid  of  danger 
except  in  cases  which  are  already  moribund,  and  because  of  this  one 
should  not  hesitate  to  operate  early,  particularly  when  other  measures 
have  proved  ineffective. 

The  irrigants  and  sedative  remedies  employed  following  these  opera- 
tions are  the  same  as  those  recommended  for  entamebic  colitis,  where 
the  solution  is  introduced  through  the  anus.  With  an  artificial  inlet 
at  the  head  of  the  large  gut  and  a  perforated  self-retaining  anal  dilator 
in  place  one  can  practice  through-and-through  colonic  irrigation  until 
the  intestine  is  completely  freed  of  irritating  gas,  toxins,  discharges, 
and  feces,  and  the  lesions  are  left  perfectly  clean  by  using,  if  necessary, 
several  quarts  of  the  fluid.  In  this  way  stronger  solutions  can  be  used, 
and  less  discomfort  accompanies  or  follows  the  irrigation  than  when 
the  flushing  is  done  from  below,  because  the  irrigant  passes  directh- 
through  the  gut  and  is  not  retained  to  cause  distention. 

The  following  surgical  procedures,  named  in  the  order  of  their  use- 
fulness, have  been  employed  with  more  or  less  frequency  in  the  treat- 
ment of  entamebic  and  other  forms  of  colitis: 

(i)  Gant's  enterocecostomy,  which  provides  a  means  of  simulta- 
neously or  separately  irrigating  the  colon  and  small  intestine. 

(2)  Cecostomy. 

(3)  Appendicostomy. 

(4)  Appcndicocecostomy. 

(5)  Exclusion  (colonic). 

(6)  Enterostomy. 

(7)  Colostomy. 

(8)  Resection  and  amputation. 

The  technic  and  criticism  of  and  indications  for  these  operations 
in  the  treatment  of  dysentery  and  other  inflammatory  and  ulcerative 
lesions  of  the  intestine  which  cause  diarrhea  will  be  fully  discussed  in 
Chapters  XLVIII-EI,  devoted  to  the  Surgical  Treatment  of  Diar- 
rheal, Inflammatory,  and  Parasitic  Diseases  of  the  Gastro-intestinal 
Tract,  and  re(iuire  no  further  elucidation  here. 


392  ENTAMEBIC    COLITIS,    DIARRHEA    IN 

Treatment  of  Tropical  or  Entamebic  Hepatic  (Liver)  Abscesses. 
— Liver  abscesses  arising  from  eiiiamebic  (d>-senteric)  colitis,  discussed 
elsewhere,  may  be  multiple,  small  or  single,  and  large,  but  the  former 
are  more  often  complicated  by  general  sepsis,  and  are  not  amenable 
in  most  instances  to  surgical  treatment. 

Tropical  abscesses  (caused  by  Entamoeba  histolytica)  are  a  common 
complication  of  entamebic  colitis  (dysentery)  in  all  stages  of  the  dis- 
ease, and  have  in  a  few  instances  been  observed  in  connection  with 
bacillary  colitis.  Tropical  abscesses  are  usually  single  and  large,  but 
may  be  multiple  and  small.  In  more  than  50  per  cent,  of  cases  they 
are  located  in  the  right  liver  lobe.  They  vary  from  a  small  lemon 
to  a  large  apple  size,  are  ovoid  in  form,  fluctuating,  and  contain  a  red- 
dish or  green  tinted  fluid,  blood-clots,  degenerated  liver  tissue,  pus  or 
gangrenous  tissue,  according  to  the  acuteness  and  virulence  of  the 
infection. 

Having  discussed  the  etiology,  pathology,  diagnosis,  and  prognosis 
of  tropical  liver  abscesses  in  connection  with  entamebic  dysentery  (see 
pp.  364-369),  the  author  will  now  point  out  the  best  methods  of 
handling  them. 

Surgical  Treatment. — Some  surgeons  aspirate  liver  abscesses,  but 
this  is  a  pernicious  practice,  and,  except  for  diagnostic  purposes,  should 
be  abandoned  in  favor  of  radical  operations,  which  enable  the  surgeon 
to  explore,  clean,  and  drain  the  abscess  and  determine  if  there  are  other 
infected  foci. 

In  exceptional  cases  where  the  abscess  bulges  the  skin  and  deeper 
structures  upward,  it  should  be  incised,  evacuated,  and  drained, 
using  a  large  tube. 

High  abscesses  are  most  easily  reached  by  removing  portions  of 
the  ninth  and  tenth  ribs  posterior  to  the  midaxillary  line,  those  farther 
back  by  a  cut  along  the  posterior  line  of  the  scapula,  and  those  situ- 
ated lower  down  by  a  vertical  incision  through  the  right  rectus. 

When  the  organ  has  been  exposed  the  liver  tissue  is  bored  through 
with  suitable  forceps  until  the  abscess  cavity  has  been  entered,  follow- 
ing which  a  fairly  tight-fitting  drainage-tube  is  inserted  and  packed 
about  with  gauze.     Finally,  the  wound  is  closed  at  each  end. 


CHAPTER   XXXIII 

BACILLARY  COLITIS  (BACILLARY  DYSENTERY,  ASYLUM 
DYSENTERY;,  DIARRHEA   IN 

HISTORY,  ETIOLOGY 

History 

BACILLARY  colitis  (dysenterv')  was  first  described  superficially  by 
ChantnissandWidai,  but  it  remained  for  Shiga  (1897)  to  discover  and 
identify  the  organism  (Bacillus  dysentericC,  Figs.  69,  70)  responsible  for 
the  loose  and  bloody  stools — viz.,  a  bacillus  of  marked  pathogenic 
properties  which  morphologically  resembles  the  colon  bacillus,  but 
differs  from  it  in  that  it  fails  of  motility,  lacks  gas-producing  qualities 
from  fermenting  sugars,  is  more  pathogenic,  possesses  a  higher  degree 
of  irritability  for  the  mucosa,  and  is  not  the  same  in  its  agglutinating 


"\. 


•5i^^ 


?^r^^ 


Fig.  69. — Bacillus  dysenterise.     Colony  on 
gelatin,  four  days;  X  20.     (Doerr.) 


'I 


;^  i- 


/ 


Fig.  70. — Bacillus  dysenteria:  from  agar 
culture.  Fuchsin  stain.  Zettnow  prep. 
(Kolle  and  Wassermann.) 


characteristics.  This  pathogenic  agent  bears  the  name  Shiga,  and  was 
in\ariably  found  by  its  discoverer  in  the  stools  or  superficial  layers  of 
the  mucous  membrane  of  persons  afflicted  with  epidemic  dysentery 
when  the  examination  was  made  during  the  crises;  but  Shiga,  in  a 
number  of  instances,  was  unable  to  demonstrate  the  presence  of  his 
bacillus  in  the  dejecta  of  healthy  individuals  and  those  afflicted  with 
other  gastro-intestinal  affections. 

Flexner  and  Strong,  two  years  later  (1900),  while  investigating 
dysentery  in  the  Philippines,  discovered  bacilli  some  of  which  corre- 

393 


394  BACILLARY    COLITIS.    DIARRHEA    IN 

sponded  to  the  Shiga  bacillus  and  others  which  differed  materially 
from  it.  Shortly  thereafter  Kruse  had  a  similar  experience  while 
studying  dysentery-  among  asylum  patients;  that  is,  he  encountered 
the  true  Shiga  organism  and  bacilli  which  resembled  it  from  a  culture 
point  of  view,  but  differed  in  their  agglutinating  and  other  distinguish- 
ing features. 

Within  the  next  three  years  Du\al  and  Bassett,  Park  and  Dunham, 
and  Hiss  and  Russell  discovered  bacilli  which  they  believed  to  be  an 
etiologic  factor  in  dysentery-  which  differed  in  one  way  or  another  from 
the  organism  originally  described  by  Shiga.  These  and  other  inves- 
tigators conceded  the  individuality  and  pathogenicity  of  Shiga's  bacil- 
lus in  some  epidemics  of  dysentery-,  but  found  that  in  others  a  different 
organism  independently  caused  the  disease. 

WTiile  investigating  a  dysenteric  epidemic  at  Seal  Harbor,  Maine, 
and  other  widely  separated  places.  Park  and  Dunham  discovered  a 
bacillus  somewhat  like  Shiga's,  but  which  differed  in  its  agglutinating 
characteristics  and  produced  indol  in  a  peptone  solution.  Duval  and 
Bassett.  while  examining  the  dejecta  of  patients  affficted  with  summer 
diarrhea,  found  an  organism  which  they  thought  was  that  of  Shiga, 
but  which  they  later  found  to  belong  to  the  Flexner  type. 

After  thoroughly  investigating  epidemic  dysenten,'  in  Europe, 
Martini  and  Lentz  made  a  report  (1902)  which  supported  the  claim 
of  Shiga  in  that  his  bacillus  was  the  chief  etiologic  factor  in  true  dysen- 
tery- and  does  not  ferment  mannite. 

They  also  pointed  out  that  the  Flexner.  Strong.  Kruse.  Park.  Duval, 
Hiss  and  Russell,  and  other  bacilli  differed  from  the  Shiga  organism  in 
their  glutins  and  power  to  ferment  mannite,  which  the  Shiga  bacillus 
lacks.  Vaillard  and  Dopter  maintain  that  in  France  domestic  dysen- 
tery- {Dysenteric  nostras)  is  always  of  bacillan.-  origin,  and  that  the 
serum  of  such  patients  agglutinates  the  cultures  of  the  Shiga  and  Flex- 
ner organisms,  but  that  this  does  not  obtain  in  the  amebic  form  of  the 
disease,  and  suggest  that  this,  like  Widal's  method  in  typhoid,  be 
employed  to  differentiate  betvveen  the  bacilhry  and  amebic  forms  of 
dysenteric  colitis. 

The  Germans  claim  that  true  d\-senter\"  is  caused  by  the  Shiga 
bacillus,  while  Americans  maintain  that  it  may  be  induced  by  either 
this,  the  Flexner-Philippine.  or  other  t\-pes  of  bacilli.  In  order  to 
establish  the  causative  relations  of  the  diff"erent  forms  of  bacilli  to 
dysenten.-  Park  thoroughly  investigated  several  acute  epidemics  of 
the  disease  that  occurred  in  New  York  City,  Sheepshead  Bay,  Seal 
Harbor,  Me..  Orange.  X.  J.,  and  at  Riker's  Island  penitentiary-.  In 
all  cases  the  patients  suffered  from  typic  dysenteric  stools,  but  in  some 
instances  the  disease  was  more  severe  than  in  others.  These  investiga- 
tions demonstrated  that  in  some  places  the  disease  was  caused  by  the 
Shiga  t^'pe,  and  in  others  by  bacilli  of  the  Flexner-Philippine  variety. 

The  Shiga  organism  was  usually  encountered  when  the  disease 
was  severe  and  the  mortality  high,  but  was  absent  in  cases  of  diarrhea 
except  in  the  presence  of  typic  dysenteric  symptoms,  while  bacilli 


HISTORY  395 

of  the  Flexner  variety  were  discovered  only  in  the  dejecta  of  patients 
who  suffered  from  the  milder  forms  of  dysentery  (colitis). 

In  discussing  the  relationship  of  the  mannite-fermenting  varieties 
to  dysentery  (Flexner,  Strong,  Kruse,  Park,  etc.)  Park  says:  "The  cul- 
tures isolated  by  us  from  over  40  cases  were  found  to  fall  largely  into 
two  distinct  types,  one  of  which  differs  from  the  Shiga  bacillus  more 
radically  than  the  other.  The  variety  nearest  to  the  Shiga  bacillus 
has  the  characteristics  of  the  culture  which  was  isolated  by  us  at  Seal 
Harbor,  Me.,  in  August,  1902,  and  the  other  variety  is  represented  by 
the  Flexner- Philippine  type. 

"The  first  type  differs  from  the  Shiga  bacillus  in  its  agglutinating 
characteristics,  and  in  that  it  produces  considerable  indol  in  a  pep- 
tone solution  and  ferments  mannite  with  the  production  of  acids. 
The  second  type  differs  in  these  points,  and,  in  addition,  in  its  agglu- 
tinating characteristics  and  in  fermenting  chemically  maltose  in 
peptone  solution." 

i\be  isolated  from  the  stools  of  dysenteric  patients  in  Japan  an 
organism  whicii  was  neither  a  known  bacillus  or  entameba  which  he 
considered  the  cause  of  the  trouble.  These  bacilli  were  more  or  less 
agglutinated  by  the  blood-scrum  of  patients  affected  with  dysentery 
down  to  a  solution  of  i  :  10,000,  which  did  not  obtain  with  the  colon 
bacillus.  MorphoUjgically,  these  bacilli  resembled  the  colon  group  and 
had  a  liveh'  motion,  formed  gas  in  grape-sugar  media,  and  coagulated 
milk.  Animal  experimentation  showed  the  organisms  to  be  weakly 
pathogenic  for  rabbits,  guinea-pigs,  mice,  and  sparrows  when  applied 
subcutaneously  and  within  the  peritoneum,  and  non-pathogenic  when 
administered  by  mouth. 

Bacillary  colitis  (bacillary  dysentery)  in  some  instances  is  probably 
due  to  a  mixed  infection,  since  the  Shiga  and  other  varieties  of  dysen- 
teric bacilli  have  been  found  associated  in  the  same  case  a  number  of 
times,  and  these  organisms  have  been  discovered  along  with  entamebse 
and  other  parasites  in  the  dejecta  of  patients  afflicted  with  the  disease. 

From  the  foregoing  it  would  seem  that  we  are  justified  in  assuming 
that  dysentery  may  be  caused  by  bacilli  of  the  Shiga,  Flexner,  Kruse, 
Strong,  Hiss,  Duval,  or  Park  varieties  and  possibly  their  strains.  Re- 
cent investigations  indicate  that  there  are  still  other  organisms  con- 
cerned in  the  production  of  summer  diarrhea  and  other  inflammatory 
and  ulcerative  lesions  of  the  bowel  which  will  in  all  probability  be  iso- 
lated in  the  near  future.  NodouJjt  in  many  instances  the  bowel  disturb- 
ance results  from  or  is  aggravated  by  the  above-mentioned  dysenteric 
bacilli,  colon  bacilli,  streptococci,  staphylococci,  and  other  organisms. 

According  to  Park,  there  are  three  varieties  of  bacilli  direct!},-  con- 
cerned in  the  production  of  dysentery:  (a)  the  non-mannite  group;  (b) 
the  mannite-forming  group  (but  not  maltose) ;  and  (c)  the  variety  wiiich 
ferments  both  mannite  and  maltose. 

Kruse  (1900)  suggested  that  bacillary  d\'sentery  should  be  grouped 
under  tivo  headings:  (i)  True  dysentery,  caused  by  the  organisms  of 
the  Shiga-Kruse  variety,  and  (2)  Pseudodysentery,  induced  by  bacilli 


396  BACILLARY    COLITIS.    DIARRHEA    IN 

of  the  Flexner,  Strong,  Park,  Duval.  Hiss,  etc.,  types;  but  this  ar- 
rangement has  not  been  generally  accepted,  probably  because  it  has 
been  demonstrated  that  the  latter  or  mannite-fermenting  varieties  of 
bacilli  are  unquestionably  the  specific  agents  of  epidemic  and  endemic 
dysenter\'  in  a  fair  proportion  of  cases. 

Kruse  selected  the  term  pseudodysentery  because  the  disease 
associated  with  the  Flexner,  Strong,  Park,  Hiss,  and  Duval  bacilli  is 
encountered  less  often  in  great  epidemics  and  is  ver\'  much  less  malig- 
nant than  dysenter\-  consequent  upon  the  Shiga-Kruse  organism. 
He  admits,  however,  that  his  pseudodysentery  may  occasionally  assume 
an  equally  grave  character,  both  in  epidemic  and  individual  cases, 
under  which  circumstances  all  the  clinical  signs  of  the  true  disease 
are  present. 

Park  prefers  to  restrict  the  name  dysentery  to  the  disease  caused 
by  bacilli  of  the  Shiga  class,  and  to  apply  the  term  paradysentery  to 
dysenteries  induced  by  the  other  varieties  which  more  closely  resemble 
the  colon  group  of  bacilli,  in  that  they  produce  indol  and  have  a  greater 
range  of  activity  in  fermenting  carbohydrates,  but  his  arrangement  is 
not  altogether  satisfactory-. 

Since  the  different  bacilli  concerned  in  the  production  of  the  disease 
possess  individual  characteristics,  would  it  not  be  better  to  group 
them  all  under  one  heading,  dysenteric  (or  dysentery)  bacilli,  and  then 
identify  them  in  different  cases  where  they  are  the  inciting  cause.-' 

With  this  understanding  there  would  be  less  confusion,  and  dysen- 
ter\-  would  fall  under  two  chief  classes — viz.,  entatnebic  and  bacillary — 
forms  of  colitis  easily  distinguished  from  those  induced  by  Balantidium 
coli.  coccidia.  flageUata.  ciliata.  etc. 

Classification  of  Bacilli  Concerned  in  Bacillary  Colitis  (Dysentery). 
— Shiga  has  formulated  five  types  of  dysenteric  bacilli — (i)  splits  onh- 
dextrose  (Shiga);  (2)  splits  dextrose  and  mannite;  (3)  splits  dextrose, 
mannite.  and  saccharose;  (4)  splits  dextrose,  mannite,  saccharose, 
and  maltose;  (5)  behaves  like  (4),  except  during  its  growth  in  mannite- 
litmus-peptone  and  water  the  original  acid  reaction  later  becomes 
alkaline.  He  does  not  agree  with  Lentz  that  these  organisms  can  be 
differentiated  exclusively  upon  their  mannite-forming  characteristics, 
nor  does  he  believe  that  any  of  them  should  be  designated  as  pseu- 
dodysentery bacilli,  as  compared  with  true  dysenteric  bacilli,  according 
to  the  plan  of  Kruse. 

]Marceau  claims  to  have  disco\ered  two  new  varieties  of  bacilli, 
one  motile,  the  other  immotile,  which  belong  to  the  aerobic  type,  and 
are  characterized  by  the  absence  of  acid  and  gas  formation,  which  he 
believes  to  have  a  causal  relation  to  dysentety. 

Upon  the  basis  of  our  present  knowledge  relative  to  the  organisms 
concerned  in  the  causation  of  bacillaty  dysenteric  colitis,  it  is  impossible 
to  classify  them  in  a  satisfactoty  manner  because  they  differ  in  their 
mannite-fermenting,  chemical,  agglutinating,  and  other  characteris- 
tics, and  because  new  organisms  believed  to  have  a  causal  relation  to 
the  disease  are  almost  constantly  being  added  to  the  list. 


CLASSIFICATION    OF    BACILLI    CONCFRNED    IX    BACILLARY    COLITIS      397 

In  a  general  way  so-called  dysenteric  bacilli  can  be  grouped 
under  two  headings,  viz.: 

(i)  Non-mannite  fermenting,  as  represented  by  the  Shiga  bacillus; 
(2)  mannite  fermenting,  typified  by  the  Flexner-Philippine  bacillus 
and  related  strains  as  represented  by  the  organisms  of  Strong,  Park, 
Hiss  (Y),  Duval,  Abe,  Dopter,  Gierswald,  Morcul,  Deycken,  etc. 
Calmetti  and  Maggiora  have  also  encountered  the  Bacillus  pyocyaneiis 
both  in  dysentery  and  infantile  diarrhea.  IJ)unham  has  described  a 
minute  micrococcus  which  he  isolated  from  tlie  l)lood,  liver,  spleen, 
kidney,  and  bile  in  several  cases  of  asylum  dysentery,  and  Manson 
says  there  are  grounds  for  supposing  that  this  organism  may  prove  to 
be  responsible  for  at  least  one  variety  of  the  disease  occurring  in  these 
institutions. 

Shiga  bacilli  are  more  often  concerned  in  great  epidemics  in 
asylums  and  elsewhere  than  the  Flexner  variety,  which  is  more  often 
encountered  in  endemic  dysenteric  colitis;  but  both  possess  quali- 
ties which  permit  them  for  a  long  time  to  withstand  variable  tem- 
peratures and  other  tests,  or  to  be  transported  from  one  place  to  an- 
other by  carriers  and  to  cause  colitis  under  favorable  conditions. 

As  a  rule,  a  single  organism  is  the  cause  of  the  trouble  in  the  same 
epidemic,  though  the  type  is  prone  to  difTer  in  other  outbreaks  of  the 
disease;  but  cases  have  been  recorded  where  two  varieties  of  bacilli,  or 
one  and  entamebic,  have  been  encountered  in  the  same  individual, 
which  would  indicate  that  a  mixed  specific  infection  had  taken  place. 
No  doubt  the  lesions  inaugurated  by  dysenteric  bacilli  are  materially 
furthered  by  bacteria,  coli  commune,  streptococci,  staphylococci, 
paratyphoid,  and  other  accidental  and  obligate  micro-organisms 
within  the  bowel;  microbes  which  are  also  capable  of  preparing  the 
field  for  specific  agents  of  dysenteric  colitis. 

Most  investigators  concede  that  the  bowel  lesions  and  manifes- 
tations consequent  upon  infection  by  Shiga  bacillus  are  more  severe 
than  those  caused  by  the  Flexner  and  related  organisms. 

When  it  is  desirable  from  a  clinical  standpoint  to  indicate  the  dif- 
ference in  malignancy  between  the  two  types  of  infection,  this  could 
be  done  by  designating  the  former  (Shiga  type)  as  bacillary  dysenteric 
colitis,  and  the  latter  (Flexner  and  related  types)  bacillary  dysenteroid 
colitis  (author). 

The  different  characteristics  of  dysenteric  bacilli  and  allied  groups 
of  micro-organisms  have  been  concisely  given  on  p.  398.  (After 
Manson^). 

In  addition  to  the  culture-media  and  other  tests  shown  in  the 
table,  the  effects  of  Gram's  stain,  bile  salt  broth,  mannite  nutrose 
broth,  rafftnose  nutrose  medium,  salicin  nutrose  medium,  caffein 
medium,  and  agglutination  with  enteric  fever  serum  were  also  tried. 
The  effects  were  as  follows:  Gram's  stain,  "decolorized"  with  all  nine 
bacilli.  Bile  salt  broth,  "acid,  no  gas,"  for  the  first  eight  bacilli;  "acid 
and  gas"  for  the  Bacillus  coli  communis.  Mannite  nutrose  broth, 
1  Tropical  Diseases,  1907,  pp.  438,  43Q- 


398 


BACILLARY    COLITIS,    DIARRHEA    IN 


^ 

^  u 

i£  E  E  >>.S 

2 

•5  i;   . 

#F'"_ 

X 

_3 

a 

1 

"  ?  S 

.S 

^1  ill 

§ 

^ 

u 

>. 

T3 

-^ 

12 

12 

_• 

1 

c 

3 

= 

=^ 

=^ 

— 

> 

z 

Z 

z 

3 

c 

c~'S  ^'"5 

>i 

w 

5 

= 

^i^ 

y-S 

lllll 

u 

1 

|£seI 

0 

X 

^ 

_u 

j5 

C  c  ^ 

—  > 

i;   cJ 

E 
0  k 

a 

^ 

I'z? "  1 

^ 

-= 

= 

" 

S 

l^ls^ 

y  — 

*^  s  Stj  j= 

«^ 

P4 

*n 

c—  =  0  c 

U  — 

5  c'S  ti 

o.y 

3 

S 

2s&^i 

0 

i 

.-s 

- 

-■j 

15 

= 

= 

= 

13 

^  i 

> 

^iis& 

j^ 

< 

>.  t-  i_l  c 

"^ 

TT 

T" 

0 

0 

_; 

^ 

^ 

^?i 

<4 

or. 

— 

— 

— 

'e 

||-:1i 

_ 

=; 

y 

c 

Z 

.•i 

< 

a; 

.ti  E 

= 

£ 

C_3 

'0 

H 

C 

z 

< 

3 

5'u  i  3  i' 

-TL 

y 

£ 

1 

1^ 

:s 

:| 

± 

a 

-z 

^  ii  >> 

"3.  -^ 

1= 

1 

>!S_ 

s 

^ 

c 

"7 

S  i  i 

c2 

•a 
2 

l-s 

c 

1 

u 

u 

0  0 

^ 

w 

c 

i'     ~ 

■=•§ 

C.  c3     . 

3 

5  ^ 

E 

3 

>.      3    ■ 

b  '-'^3 
£■3   3*3 

>- 

Z 

^'■^2 

'^ 

"T" 

■r 

■~ 

•r 

-"o 

O 

z 

-^ 

= 

= 

= 

— 

= 

< 

— 

'— 

zr. 

III 

U 

^ 

c 

"o-^ 

»J 

'S  £• 

1-2 

i  ^  _. 

art 

U 

£  -^ 

E 

< 

_).y  b"© 

^^    C 

PQ 

i^ 

■|tl.l 

1 

1 

2 

j' 

% 

^ 

r^ 

fe 

■" 

"" 

■~ 

— 

"" 

"- 

"- 

— 

o 

c/5 

tr. 

^ 

i  i  E-r  = 

X 

1 

> 

1 

_> 

■= 

■=_£  ^ 

I-'  J  ^ 
0  -  c    . 

U 

Z 

< 

y: 

0  >>-  S'~ 

1 

jT. 

f 

-^ 

= 

s 

j= 

.  "  >> 

u  2  S^ 

o 

1 

1-1  it  1 

C 

_>i 

S 

X 

i> 

1 

1 

3 

:d 

13 

K:"t:  3 
ESS 

g 

r2 

15 

IS  i  c  § 

g  E  s  M 

C-i 

v: 

X. 

U 

< 

< 

^  3: 

c            — 

•  "p  —  3  -y. 

1 

"H 

" 

1 

>. 

•X. 

£ 

3  3 

"5    -y" 

5"^  3 

1-3 
< 
OS 

0 

i 

x" 

•f. 

1 

I 

g 

JT 

"5— 

Ic 

:^ 

:i 

s~~ 

y 

rs 

i_  — 

_ 

^^ 

^ 

s2'E-|5 

2 

^. -^ 

5 

^ 

c3 

u 

"3 

^ 

1 

t£ 

^ 

^ 

■i, 

S 

_>< 

Q 
Z 

< 

tc 

•€ 

1 

1 

—  c 

11 

1.5 

f 

3 

0 
0 

u 

'"' 

"^ 

z 

■> 

:d 

*"> 

s 

> 

H 

— 

o 

i    g    K    >.>^ 
u   u";  — ^    3 

S>-  = 

C 

c  2  >. 

o 

>. 

3 

:=  "^ 

— 

i: 

-r.   i 

s 

% 

""3     .:  S 

3U 

ll 

af 

•j^ 

_• 

'~  -^   r.     . 

ijil 

c 

s 

IIIIJ 

c 

2 

:i 

:s 

ri 

rj- 

:^ 

0  i'jj 

Z~ 

•| 

£ 

0 

;s 

D 

0 

"" 

—' 

— 

— 

— 

'J: 

s 

H 
O 

c 
i: 

c 

^     L. 

ll 

c 
E 

a! 

5-d 

■^:5 

g 

c 

1 

i: 

•X. 

3 
C 

u 

c 

4) 

SSS 

OS 

2 
512 

o 

en 

-■ 

c/; 

u~. 

^ 

^ 

« 

c/; 

2u 





-^30    . 

.a 

3 

/r. 

3' 

JT. 

=  y. 

•r 

jf 

_3 

v.    3    " 

_3  i-r 

•j5 

si 

-5  3 
"E 

J  E 

^A 

2=  g5 

— 

^ 

G 

c 

i'i 

£"5 

— 

y 

c 

u 

< 

■H 

15 

u 

> 

i5 

ij 

;^ 

^  s 

^ 

S 

(1< 

CLASSIFICATION    OF    BACILLI    CON'CERXED    IN    BACILLARY    COLITIS       399 

"unchanged"  for  ilu-  first  five  bacilli;  "growth  and  acid"  for  the 
pseudodysenterial  bacillus;  "acid"  for  the  last  three  bacilli.  Raffinose 
nutrose  medium  and  also  salicin  nidrose  medium,  "acid  and  growth" 
for  the  pseudodysenterial  bacillus;  "unchanged"  for  the  other  eight 
bacilli.  Caffein  medium,  "growth"  with  the  Bacillus  typhosus  abdomi- 
nalis  and  the  paratyphoid  bacilli;  "no  growth"  with  the  other  seven 
bacilli.  On  testing  with  enteric  Jever  serum  the  agglutination  result 
was  "marked"  with  the  Bacillus  typhosus  abdominalis  and  "nil"  with 
the  other  eight  bacilli. 


CHAPTER   XXXIV 

BACILLARY    COLITIS     BACILLARY    DYSENTERY,    ASYLUM 
DYSENTERY)   DIARRHEA   IN     Continued) 

PATHOLOGY 

Bacillary  colitis  fdysenten.-)  occurs  frequently  in  epidemic  form 
in  the  tropics.  Japan.  China.  India,  Europe,  and  this  countn,'  in  asy- 
lums, among  soldiers  (during  war  times),  where  large  numbers  camp 
together,  and  in  children  during  the  summer  months. 

The  bacilli  chiefly  concerned  in  its  production  are  the  Shiga, 
Flexner-Harris,  Kruse,  Strong,  Hiss  and  Russell,  Park,  Dopter,  Duval, 
etc..  but  the  manifestations  and  pathologic  changes  induced  by  the 
Shiga  organisms  are  more  serious  and  characteristic  than  those  con- 
sequent upon  infection  incited  by  the  other  above-named  bacilli. 

Dysenteric  colitis  was  thought  to  be  due.  in  a  \'ast  majority'  of 
instances,  to  entamebae  (ameba),  but  recently  it  has  been  shown  that 
bacillan,"  colitis  is  a  world-wide  disease,  and  that  bacilli  cause  intes- 
tinal infections  here,  abroad,  and  in  the  tropics  ver\'  much  more  fre- 
quently than  was  formally  supposed,  and  that  this  form  of  colitis  is 
often  mistaken  for  amebic  dysenter\-. 

Frequently  (particularly  in  the  tropical  and  semitropical  countries) 
colitis  results  from  a  dual  infection,  when  both  pathogenic  entamebse 
and  bacilli  are  present  in  the  tissues  and  dejecta.  Under  such  cir- 
cumstances the  lesions  are  not  characteristic  of  either  bacillar\-  or 
entamebic  inflammation  of  the  bowel,  and  finding  of  the  specific  organ- 
isms in  the  stools  is  necessan,-  to  complete  the  diagnosis. 

Bacillar\-  dysentery-  is  essentially  an  acute  disease,  and  the  patient 
usually  dies  or  recovers  quickly,  and  though  the  inflammatory  process 
and  accompanying  toxemia  are  intense  while  the  infection  rages,  the 
destruction  to  the  bowel  tunics  is  not  nearly  so  marked  as  occurs  in 
entamebic  colitis,  which  is  usually  a  chronic  aff^ection  complicated  by 
recurring  infections  and  progressive  encroachment  upon  the  mucous 
membrane  and  submucosa. 

While  considerable  has  been  added  to  our  knowledge  concerning 
the  pathologN"  of  bacillar\-  colitis,  the  subject  still  remains  somewhat 
obscure  as  regards  the  structural  changes  which  accompany  the  dis- 
ease in  both  adults  and  children.  In  fact,  the  descriptions  given  by 
the  authorities  of  the  pathology'  and  manifestations  incident  to  this 
type  of  infection  var\-  to  such  an  extent  that  it  is  often  difficult  to 
realize  that  they  are  discussing  the  same  aft'ection 

The    manifestations    and    pathologic    changes    which    accompany 
bacillan.-  colitis  van,-  widely,  and  may  be  slight,  moderate,  or  severe, 
according  to  the  virulence  of  the  infection. 
400 


PATHOLOGY 


401 


PecuHarK',  in  fatal  cases  the  bowel  often  exhibits  but  minor,  if 
any,  structural  changes,  especially  in  infants  and  children.  Here, 
as  in  entamebic  colitis,  the  initial  abrasions  or  ulcers  are  directly  due 
to  specific  agents  (dysenteric  bacilli),  but  the  subsequent  or  more 
extensive  lesions  are  chietiy  caused  by  the  activity  exhibited  by  other 
pathogenic  and  pyogenic  intestinal  micro-organisms  and  their  toxins, 
which  cause  a  mixed  infection. 

Epidemic  or  bacillary  colitis  is  an  acute  affection  which  extends 
over  a  period  varying  from  a  few  ddys  to  weeks,  and  which  distin- 
guishes it  from  entamebic  colitis,  which  ordinarily  endures  for  months 
or  years.  The  onset  of  the  former  is  sudden,  and  the  early  manifes- 
tations and  tissue  changes  are  intense  from  the  first,  while  the  latter 
comes  on  insidiously  and  gradually  invalidizes,  and  patients  afflicted 
with  bacillary  are  less  often  subject  to  relapses  (reinfection)  than  those 
who  suffer  from  entamebic  colitis,  though  occasionally  the  disease 
runs  a  protracted  course. 

Owing  to  intensity  of  the  inflammatory  changes  in  the  bowel  and 
marked  toxemia  incident  thereto  frequently  the  incipient  stage  of 
bacillary  infection  is  characterized  by  high  temperature,  anorexia, 
exhausting  diarrhea,  and  general  prostration,  but  after  a  few  days  the 
symptoms  become  subacute,  the  intestinal  manifestations  less  distress- 
ing, and  by  the  end  of  from  two  to  four  weeks  the  infective  process 
subsides,  the  patient  gradually  recovers  his  healthy  state,  and  the 
bowel  assumes  a  normal  appearance. 

The  absorption  of  toxins  in  bacillar\'  colitis  is  evidently  a  dangerous 
element  because  frequently  adults  and  children  die  without  discover- 
able pseudomembranes  or  microscopic  lesions  in  the  intestines. 

Some  of  the  poisons  formed  by  the  Shiga,  Flexner.  and  Kruse  bacilli, 
etc.,  act  directly  upon  nerve-centers  to  paralyze  the  extremities  and 
bladder  or  produce  other  ner\^ous  phenomena,  and  others  upon  the 
gastro-intestinal  tract,  and  cause  the  typic  symptoms  of  the  disease 
(diarrhea,  bloody  stools,  cramps,  etc.). 

The  infective  process  is  usually  confined  to  the  colon,  and  is  most 
destructive  in  the  sigmoid  flexure  and  rectum,  though  it  involves  the 
lower  ileum  more  frequently  and  to  a  greater  length  (particularly  in 
children)  than  entamebic  colitis. 

According  to  Shiga,  there  are  ''ascending  and  descending'  t\'pes,  the 
former  is  the  most  common,  and  the  infection  extends  upward  from  the 
rectum;  while  the  latter,  or  high  type,  starts  in  the  ileum  or  upper  colon 
and  works  downward. 

The  mortality  frcjm  bacillary  is  ver\-  much  higher  during  the  first 
two  or  three  weeks  than  it  is  from  entamebic  colitis,  but  ultimately 
as  many  or  more  deaths  occur  from  the  latter  as  the  former,  because 
entamebic  dysentery  is  progressive  and  destructive  to  the  intestine 
and  general  health  of  the  patient. 

Dysenteric  bacilli  primarily  attack  the  epithelium  and  then  gradu- 
ally penetrate  deeply  into  the  mucosa  in  contradistinction  to  enta- 
meba?,  which  first  pass  through  the  mucous  membrane  to  the  sub- 
26 


402  BACILLARY    COLITIS,    DIARRHEA    IN 

mucosa,  the  center  of  their  activity,  from  which  point  the  destructive 
process  works  upward  and  through  the  overlying  membrane  to  form 
ulcers.  Knowing  this,  it  is  easy  to  understand  why  the  lesions  of 
bacillan.-  are  more  superficial  and  less  devastating  than  those  of  enta- 
mebic  colitis. 

Deep  and  extensive  ulcers  rarely  complicate  the  disease  except 
when  it  is  chronic  and  there  is  a  mixed  infection  or  an  intense  infiltra- 
tion of  the  intestinal  tunics,  the  blood-vessels  strangulated,  and  where 
coagulation  and  necrosis  have  taken  place  or  extensive  sloughing 
(gangrene)  has  occurred. 

In  severe  t>pes  of  the  infection  the  submucosa  becomes  congested, 
edematous,  and  thickened,  but  rarely  undergoes  necrosis,  and  the 
lesions  seldom  involve  the  intestinal  musculature  and  peritoneum 
enough  to  cause  perforation,  as  sometimes  occurs  in  entamebic  colitis. 

It  is  impossible  to  give  a  description  of  the  patholog>-  of  bacillary 
colitis  which  would  tit  all  cases,  because  the  changes  in  the  tissues  fre- 
quently \-ar\-  in  different  individuals,  or  in  the  same  case,  where  the 
patient  is  run  down,  the  infection  is  slight,  or  extremely  virulent  in 
different  stages  of  the  disease. 

Bacillary  colitis  may  manifest  itself  in  the  catarrhal,  ulcerative, 
and  pseudomemhranous  forms,  but  small  or  extensi\e  diphtheric-like 
patches  are  present  upon  the  mucosa  in  most  cases. 

Catarrhal  bacillary  colitis,  the  mildest  form  of  the  infection,  is  more 
common  in  children  than  adults,  and  is  characterized  chiefly  by  hyper- 
emia, swelling,  and  edema  of  the  mucous  membrane,  which,  in  addition, 
shows  petechial  hemorrhages  and  hyperplasia  of  the  lymph-follicles. 

Occasionally  necrosis  takes  place  in  the  superficial  mucosa  to  a 
slight  degree,  which  results  in  the  formation  of  erosions  or  shallow 
ulcers,  under  which  circumstances  the  mucous  membrane  is  seen 
covered  with  blood-streaked  glain,-  mucus,  alone  or  admixed  with 
pus.  when  the  inflammation  is  purulent. 

Microscopic  examination  of  the  stools  demonstrates  the  presence  of 
mucus,  red  blood-corpuscles,  an  unusual  number  of  leukocytes,  various 
shaped  epithelioid  cells,  and  occasionally  necrotic  tissue  and  pathogenic 
bacilli. 

Ulcerative  bacillary  colitis  is  encountered  more  frequently  than 
the  form  just  described,  and  the  ulcers  may  appear  quickly  when 
the  infection  is  of  a  virulent  type,  or  secondarily  in  the  presence  of 
catarrhal  inflammation  or  formation  of  false  membranes,  but  the 
lesions  are  not  destructive  except  when  other  micro-organisms  than 
the  specific  bacilli  (Shiga- Flexner.  etc.)  actively  participate  in  the 
infective  process;  consequently,  when  the  bacillary  inflammation 
subsides  the  bowel  shows  little  or  no  evidence  of  the  infection. 

Both  catarrhal  and  ulcerative  lesions  are  common  to  the  lower  ileum 
and  colon,  and  are  but  rarely  encountered  in  the  upper  small  intestine. 
When  ulcerated  the  mucosa  may  be  of  a  dark  bright  red,  purple,  or 
dark  brownish  color  in  difterent  cases,  and  the  lesions  ma\"  be  single 
or  in  groups,  small  or  large,  superficial  or  deep,  ovoid,  encircling  or 


PATHOLOGY 


403 


irregular  in  shape,  have  clear  cu I,  elevated,  or  uiuleriniiied  edges  and 
clean  or  necrotic  bases  smeared  with   mucus,  according  t(;  the  viru 
lence  and  stage  of  the  disease   and    part    i)Ia\-ed   1)\-  mixed  infection 
(Fig.  71). 


-'^WtrV^ 


Fig.  71. — Chronic  colonic  bac  illary  colitis  (i)a(  illary  dyscntcr}')  with  (li])htheric  ulcers.' 


Sometimes  diminutive  and  large  ulcers  are  present,  or  coalescence 
can  be  seen  taking  place  between  adjacent  lesions,  and  occasionally  the 
colon  is  denuded  of  its  mucosa  from  one-third  to  one-half  its  extent,  in 
which  case  the  ulcerative  stage  has  usualh'  been  preceded  by  a 
deep-seated,  diphtheric  inflammation  which  resulted  in  gangrene  and 
sloughing  of  the  tissues. 

1  .Army  Med.  Museum. 


404 


BACILLARY    COLITIS,    DIARRHEA    IN 


The  solitary  glands  and  agminated  follicles  are  usually  swollen, 
edematous,  and  may  undergo  necrosis,  and  the  mucous  folds  are 
congested,  thickened,  and  sometimes  present  as  corrugated-like 
transverse  ridges,  while  the  mucous  membrane  between  them  may  show 
dark,   petechial   hemorrhagic  areas  or   diminufixc   or   larger   grayish 


Fig.  72. — Bacillary  colitis  (bacillary  dys-       Fig.   73. — Sloughing  pseudomembranous 
entery)  with  pseudomembranous  (diphtheric)  (diphtheric)  dysentery  of  the  rectum.- 

sloughing  of  the  cecum.' 


membranous    patches,  which    when  wiped  ofl   leave  a  \'isible  highly 
reddened  mucosa. 

The  ulcerative  and  inflammatory  lesions  seldom  in\olve  the  sub- 
mucosa  or  deeper  structures;  consequently,  the  intestinal  wall  is  not 

^  Army  IMed.  Museum. 

2  Med.  and  Surg.  Hist.  War  of  Rebellion. 


PATHOLOGY  405 

SO  thick  as  in  entame])ic  colitis,  and  peritonitis  is  a  rare  complication, 
though  the  peritoneum  frecjuently  appears  congested,  thickened,  and 
moist. 

In  excejnioiial  cases  of  bacillary  ulceration,  where  the  rectum  and 
sigmoid  are  riddled  with  lesions,  the  bowel  is  constantly  bathed  in  a 
bloody  mucopurulent  discharge,  the  mucous  membrane  and  skin  of 
the  perianal  region  is  excoriated,  and  when  seeds,  feces,  or  infective 
material  become  pocketed,  diminutive  abscesses  and  fistulee  result. 

In  the  rapidly  progressive  or  fulminating  type  of  bacillary  colitis 
(d>-sentcry),  which  freciucnlly  ends  fatally  within  the  first  week,  ulcera- 
tion may  or  may  not  occur,  but  toxemia  in\ariably  features  the  disease 
and  often  causes  death. 

In  these  cases  the  mucosa  appears  intensely  inflamed,  swollen, 
and  superficially  necrotic  over  extensive  areas,  or  throughout  the  colon 
and  occasionally  the  lower  ileum,  and  exhibits  highly  colored,  small 
hemorrhagic  areas  and  elevated,  congested,  enlarged  solitary  follicles 
or  a  characteristic  diphtheric  membranous  covering. 

The  necrotic  membrane  which  forms  here  is  composed  chiefly  of 
coagulated  mucus,  epithelium,  leukocytes,  red  blood-corpuscles,  live 
and  dead  micro-organisms,  and  tissue  debris,  and  is  detachable  in  some 
instances  without  injury,  but  in  others,  w'here  the  inflammation  and 
destructive  process  is  deep  seated,  removal  of  this  pseudomembrane 
leaves  a  granulating,  superficially  or  extensively  ulcerated  mucosa 
(Fig.  72). 

It  has  not  been  conclusively  shown  whether  the  infective  process 
starts  in  the  lymph-follicles  or  is  incident  to  the  irritati\"e  action  of 
bacilli  and  their  toxins  upon  the  mucosa,  which  results  in  the  destruc- 
tion of  the  epithelium  and  formation  of  an  exudative  membrane,  which 
later  sloughs. 

Statistics  indicate  that  in  epidemic  bacillary  colitis  ulcers  occur 
in  50  per  cent,  in  adults,  and  25  per  cent,  of  the  cases  in  infants  and 
children  appear  at  the  end  of  the  first  week,  are  active  for  two  weeks, 
and  show  a  tendency  toward  healing  in  from  three  to  five  weeks. 

During  a  serious  epidemic  of  bacillary  dysentery  at  the  Danvers 
(Mass.)  State  Hospital  (1908),  of  16  deaths  recorded,  the  accompany- 
ing statistics  give  the  time  patients  lived  after  the  infection  started: 

Cases  dj'iriK  in  from  six  to  eight  days  after  onset 7 

Cases  dying  in  from  eleven  to  sixteen  da\s  after  onset 6 

Cases  dying  in  from  twenty-one  to  thirty-ti\e  days  after  onset. .  3 

Pseudomembranous  Bacillary  Colitis. — The  presence  of  a  false 
or  diphtheric  membrane  is  the  pathognomonic  sign  of  bacillary  inflam- 
mation (Shiga,  Flexner,  Kruse,  etc.,  types)  in  the  vast  majorit\-  of 
instances,  and  forms  when  the  mucosa  is  involved  in  a  catarrhal 
hemorrhagic  or  true  diphtheric  process  in  anyw-here  from  one  to  two 
weeks  (Figs.  72,  73).  This  pseudomembrane  may  embrace  the  substance 
of  the  mucosa  or  form  upon  it,  in  which  case  it  can  be  removed  with 
a  curet  or  wiped  off  through  the  sigmoidoscope  with  a  swab,  but  in 


406  BACILLARY    COLITIS,    DIARRIIKA    I\ 

either  case  necrosis  ensues  to  a  slight  or  serious  degree,  and  the  diph- 
theric covering  gives  way  when  the  highly  reddened,  smooth,  or  un- 
even ulcerated  underlying  mucosa  becomes  visible.  This  condition 
prevailed  in  i8  per  cent,  of  the  28  cases  of  the  disease  in  infants  inves- 
tigated by  Howland,  and  in  26  per  cent,  of  the  9  adult  cases  examined 
at  the  Danvers  Hospital. 

The  pseudomembrane,  which  may  cover  a  small  area,  a  single  seg- 
ment, or  all  the  lower  bowel,  is  alive  with  a  specific  bacilli  (dysenteric), 
cocci,  and  other  micro-organisms.  In  the  underlying  congested  mucosa 
are  to  be  found  sw^ollen  and  degenerating  solitary  follicles,  necrosis  of 
the  interglandular  structures,  dilatation,  and  partial  or  complete  stran- 
gulation of  the  blood-vessels,  and  in  aggravated  cases  thickening,  ede- 
ma, or  breaking  down  of  the  submucosa. 

In  rare  instances  the  necrotic  membrane  embraces  the  superficial 
intestinal  tunics  to  a  greater  or  less  extent,  and  comes  away  in  strips 
or  casts  shaped  like  the  bowel,  following  which  the  intestine  may  re- 
main thick  and  hardened,  undergo  atrophic  changes,  or  strictures 
may  form  at  points  in  the  bowel  where  the  destruction  of  tissue  has 
been  extensive. 

Intestinal  steftosis  is  a  complication  of  entamebic  very  much  more 
frequently  than  bacillary  colitis,  and  in  either  case  the  stricture  is 
located  more  often  in  the  rectum  than  in  the  colon  or  sigmoid  flexure. 

Liver  abscess  is  rarely  induced  by  bacillary  infection,  but  myo- 
carditis, cardiac  hypertrophy,  valvular  and  circulatory  disturbances, 
nephritis,  phlebitis,  paraplegia,  hepatic  congestion,  meningitis,  chole- 
lithiasis, and  bronchopneumonia  have  been  more  or  less  frequent 
complications  of  the  disease,  and  it  has  been  noted  that  bacillary  colitis 
lowers  the  resistance  of  the  patient  so  that  he  readily  contracts  other 
infectious  diseases,  such  as  typhoid  fever,  pneumonia,  tuberculosis, 
cholera,  and  diphtheria. 


CHAPTER   XXXV 

BACILLARY  COLITIS   (BACILLARY  DYSENTERY,   ASYLUM 
DYSENTERY),   DIARRHEA   IN   (Continued) 

SYMPTOMS,  DIAGNOSIS 

Symptoms. — In  this  condition  the  manifestations  are  variable, 
the  disease  may  be  very  acute  or  chronic,  or  more  virulent  in  one  case 
than  another,  the  symptoms  are  worse  and  the  mortality  greater  when 
the  infection  is  induced  by  Shiga's  than  when  it  is  incident  to  the 
bacilli  of  Flexner,  Park,  Strong,  Hiss,  Duval,  or  related  organisms. 

In  some  instances  patients  are  desperately  ill  throughout  the 
attack,  the  accompanying  symptoms  are  out  of  all  proportion  to 
the  intestinal  lesions,  and  they  may  be  difftcult  or  impossible  to  dis- 
cover. Children  arc  infected  with  Shiga's  bacillus  less  often  than 
with  other  types  of  dysenteric  bacilli. 

The  catarrhal  form  of  bacillary  colitis  may  start  as  a  mild  diarrhea 
accompanied  by  slight  colicky  pains  and  intestinal  soreness,  the  patient 
will  have  from  four  to  six  movements  daily,  which  in  the  beginning  are 
copious  and  semisolid  or  mushy,  and  may  contain  considerable  bile, 
some  mucus,  and  little  if  any  blood,  and  defecation  causes  very  little 
straining  and  is  almost  painless.  Later  there  is  a  loss  of  appetite,  a 
feeling  of  malaise,  and  the  stools  become  fluid,  smaller,  very  much  more 
frequent  (ten  to  fifty  daily),  and  are  composed  chiefly  of  mucus  tinged 
with  blood,  and  their  expulsion,  which  is  accompanied  by  griping  pains, 
induces  considerable  straining  and  leaves  a  burning  sensation  in  the 
rectum.  In  favorable  cases  the  manifestations  may  subside  in  a  few 
days  and  the  patient  make  a  complete  recovery,  or  the  infection  may 
become  active  locally  or  extend  to  other  segments  of  the  bowel,  under 
which  circumstances  the  dysenteric  symptom-complex  becomes  exag- 
gerated. 

Ordinarily,  bacillary  colitis  is  of  a  more  sudden  onset  and  of  a  severer 
type,  in  which  case  the  patient  is  extremely  ill  from  the  beginning, 
and  complains  of  symptoms  which  indicate  that  both  the  bowel  and 
general  system  are  profoundly  affected  by  the  infection  and  absorp- 
tion of  toxins,  both  when  the  disease  is  restricted  to  the  colon  or  in- 
volves the  large  and  small  intestine,  with  the  result  that  the  sufferer 
becomes  dangerously  sick  within  forty-eight  hours  and  not  infre- 
cjuently  dies  in  from  three  to  seven  days. 

Deplorable  cases  in  the  beginning  or  later  exhibit  chill\-  sensations, 
intermittent  temperature,  which  varies  from  ioi°  to  104°  F.,  erratic, 
weak,  fast  pulse  (100  to  150),  anorexia,  thirst,  hoarse  voice,  glazed  red 
tongue,  cold   dry   skin,  aching   body,  prostration,  restlessness,  head- 

407 


408  BACILLARY    COLITIS,    DIARRHEA    IX 

ache,  severe  cramps  or  disseminated  abdominal  pain,  colonic  tender- 
ness on  pressure,  sometimes  nausea,  vomiting,  delirium,  congestion  of 
the  liver,  and  an  exhausting  diarrhea  characterized  by  diminutive, 
oij  to  §j  (8.0-30.0),  frequent  (ten  to  fifty  daily)  passages,  which  in  the 
beginning  are  feculent,  then  seromucous,  and  finally  composed  almost 
entirely  of  mucus,  tissue  debris,  and  blood,  which  shows  bright  red 
if  fresh  or  as  "coffee-ground"-like  stools  when  long  retained.  Within 
two  or  three  days  in  aggravated  cases  the  tongue  becomes  furred,  the 
skin  moist  and  relaxed,  and  the  serious  condition  of  the  patient  is 
evidenced  by  exhaustion,  collapse,  delirium  or  coma,  resulting  from  the 
absorption  of  toxins,  sepsis,  or  degree  of  fatigue  which  follows  the  loss 
of  sleep,  inability  to  digest  food,  cramps,  diarrhea,  rectal  tenesmus,  and 
small  or  considerable  loss  of  blood. 

Death  ensues  in  from  5  to  20  per  cent,  of  the  cases  within  three  to 
seven  days. 

In  favorable  cases  the  manifestations  consequent  upon  the  infec- 
tion usually  quickly  or  gradually  subside  and  the  patient  gets  well  in 
from  two  to  five  weeks,  but  occasionally  the  acute  insidiously  passes 
into  chronic  dysentery,  under  which  circumstance  the  evacuations 
continue  abnormally  frequent  or  loose  and  contain  more  or  less  mucus, 
blood,  and  pus.  The  frequency  and  fluidity  of  the  stools  and  the 
amount  of  contained  mucus  and  blood  are  invariably  augmented 
when  the  patient  takes  cold,  and  indulges  in  dietary  indiscretions,  act- 
ive exercise,  remains  in  the  broiling  sun,  or  consumes  alcohol  or  drinks 
lemonade,  highly  charged  water,  or  ice-cold  beverages. 

When  the  bowel  is  widely  ulcerated  or  extensively  involved  in 
diphtheric  or  gangrenous  processes,  mixed  infection  ensues,  and  the 
septic  condition  of  the  patient  is  observable  in  his  blood  changes  (leu- 
kocytosis, etc.),  sallow  or  muddy  complexion,  rigors,  irregular  high 
temperature,  and  the  formation  of  diminutive  or  large  abscesses  which 
open  into  the  peritoneal  cavity  or  through  the  abdominal  wall.  W^hile 
sepsis  independently  is  conducive  to  diarrhea,  the  frequency  of  the 
evacuations  are  proportionate  to  the  extent  of  raw  areas  in  the  mucosa. 
When  ulcers  are  numerous  or  entire  sections  of  the  mucous  lining  of 
the  bowel  slough  the  evacuations  are  incessant,  foul  smelling,  and 
composed  of  mucus  mixed  with  fresh  or  clotted  blood  and  fibrinous 
membrane,  or  offensive  necrotic  sloughs  variable  in  size  and  shape. 

In  deplorable  cases  of  bacillary  colitis  (dysentery)  the  patient 
becomes  chronically  ill,  convalesces  slowly,  has  occasional  relapses, 
and  may  suffer  from  indigestion  and  persistent  diarrhea  after  the 
specific  bacilli  which  caused  the  trouble  have  completely  disappeared, 
and  there  may  be  an  irritable,  inflamed,  or  ulcerated  state  of  the 
mucosa,  or  presence  of  strictures,  adhesions,  angulations,  and  other 
sequelae. 

The  COMPLICATIONS  and  sequel.^  of  bacillary  are  not  so  frequent 
or  distressing  as  those  induced  by  entamebic  colitis,  and  liver  abscess 
never  complicates  bacillary  colitis  except  in  the  presence  of  a  mixed 
infection,  but  hepatic  congestion  is  a  frequent  manifestation  of  the 


DIAGNOSIS  409 

affection.  Perforation  and  peritonitis  are  rare,  since  the  destructive 
process  is  usually  confined  chiefly  to  the  superficial  mucosa,  but  stric- 
tures occur  occasionally  when  the  mucous  membrane  has  been  denuded 
at  several  points  or  over  large  areas  by  ulcers  or  extensive  sloughing. 

Inflammation  of  joints  and  tendons,  bronchopneumonia,  pleurisy, 
albuminuria,  nephritis,  phlebitis,  pericarditis,  endocarditis,  valvular 
disturbances,  meningitis,  paraplegia,  neuritis,  splenic  enlargement  or 
abscess,  cholelithiasis,  impairment  of  the  arterial  tunics,  enlargement 
of  the  mesenteric  lymph-nodes,  intestinal  ptosis,  adhesions  and  angula- 
tions, appendicitis,  pericolitis,  sigmoiditis,  proctitis,  hemorrhoids,, 
adenomata,  enlarged  anal  papillce,  fissures,  ischiorectal  abscesses,  fistulcB, 
and  erosions  of  the  mucosa  and  gluteal  skin  have  been  encountered  at 
one  time  or  another  as  complications  of  bacillary  colitis. 

The  blood  changes  in  bacillary  dysentery  are  not  very  important, 
since  in  the  beginning  there  is  but  slight  increase  in  the  white  blood- 
corpuscles  and  lymphocytes,  which  thereafter  gradually  diminish  and 
become  normal  in  a  week  or  ten  days.  Except  in  so  far  as  influenced 
by  the  patient's  high  temperature,  toxemia,  and  a  septic  state,  the 
urinary  compliciitions  are  unimportant  and  do  not  deserv^e  special 
consideration;  deviations  from  the  normal,  caused  by  the  conditions 
mentioned,  influence  one  in  diagnosing  this  affection. 

Diagnosis. — While  the  above-enumerated  symptoms  help  one  to 
arrive  at  a  conclusion,  they  are  not  sufficiently  accurate  to  warrant 
one  in  basing  a  diagnosis  upon  them.  This  condition  has  occasion- 
ally been  mistaken  for  diarrhea  incident  to  dietary  indiscretions, 
worms,  and  balantidic  infection,  but  most  often  it  has  been  confused 
with  entamebiasis,  which  must  be  excluded  before  a  diagnosis  is  made. 

Bacillary  differs  from  entamebic  colitis  in  that  (a)  it  occurs  in  epi- 
demic form  more  frequently  (particularly  among  the  inmates  of  asy- 
lums, prisons,  barracks,  railroad  buildings,  camps,  etc.);  {b)  has  a 
more  sudden  onset;  (c)  is  accompanied  by  a  severe  type  of  toxemia; 
{d)  more  frequently  attacks  children;  (g)  is  of  shorter  duration;  (/)  is 
most  dangerous  during  the  first  week  or  ten  days;  (g)  very  often  com- 
plicated by  diphtheric  or  gangrenous  intestinal  changes;  (/z)  is  quite 
often  complicated  by  inflammation  of  the  joints  and  tendon  sheaths; 
(/)  usually  involves  the  superficial  mucosa  only;  (j)  is  less  often  com- 
plicated by  relapses  or  passes  into  the  chronic  form;  {k)  more  quickly 
subsides  or  kills  the  subject;  and  (/)  the  patient's  blood-serum  agglu- 
tinates with  Shiga's,  Flexner's,  Duval's,  and  other  dysenteric  bacilli, 
while  the  serum  of  persons  afflicted  with  entamebiasis  does  not  agglu- 
tinate with  entamebffi. 

In  all  cases  a  tentative  diagnosis  must  be  confirmed  by  finding  of 
the  specific  (Shiga,  Flexner,  Park,  Duval,  or  Hiss,  etc.)  bacilli  in  the 
dejecta  and  developing  it  by  cultivation  so  that  it  can  be  distinguished 
from  other  dysenteric  bacilli,  which  is  not  always  easy  when  the  dejecta 
is  fresh. 

Macroscopically,  one  can  determine  the  color  and  consistence  of  the 
feces  and  whether  or  not  they  contain  mucus,  pus,  blood,  shreds  of 


^lO  BACILLARV    COLITIS,    DIARRHEA    IX 

tissue,  gangrenous  sloughs,  undigested  food  remnants,  or  larger  worms, 
but  it  is  imperative  that  the  stools  be  microscopically  searched  to  de- 
monstrate whether  they  contain  diminutive  helminths  (or  their  ova), 
Balantidium  coli,  flagellates,  ciliates,  coccidia,  or  entamebae,  which 
may  induce  manifestations  closely  resembling  those  of  bacillary  colitis. 

The  aggliitinatiyig  test  which  can  be  relied  upon  to  differentiate 
bacillary  from  entamebic  colitis  cannot  be  successfully  employed  in 
every  case  to  distinguish  between  Shiga  or  true  dysenteric  bacilli  and 
so-called  pseiido-  or  parahaciUi,  as  represented  by  the  Flexner,  Hiss, 
Park,  Duval,  etc.,  types,  because  the  latter  may  agglutinate  to  a  cer- 
tain extent  with  the  blood-serum  of  healthy  individuals  and  not  always 
with  that  of  dysenteric  patients,  and  because  it  is  sometimes  difficult 
to  differentiate  between  the  specific  organisms  of  the  last-named  group. 

Martini  and  Lentz  (1902)  did  much  to  clear  up  the  subject  when 
they  pointed  out  that  bacilli  of  the  Flexner,  Hiss,  Park,  and  Duval 
strains  possess  glutins  and  a  power  to  ferment  mannite  which  were 
lacking  in  the  Shiga  organisms.  Shiga  bacilli  are  detected  propor- 
tionately more  frequently  in  severe,  and  the  Flexner  organisms  in  the 
milder  cases  (pseudodysentery)  of  bacillary  colitis,  and  the  former  most 
often  causes  the  infection  in  adults  and  the  latter  in  children. 

Park  groups  dysenteric  bacilli  into  (a)  the  non-mannite;  ib) 
mannite  fermenting  (but  not  maltose) ;  and  (c)  varieties  which  ferment 
both  mannite  and  maltose,  and  Flexner  also  recognizes  these  types 
differentiated  from  each  other  as  follows: 

"(i)  Shiga  type  attacks  glucose  without  action  on  other  sugars, 
including  mannite  and  lactose.  (2)  Flexner-Harris  type  attacks 
glucose  and  mannite.  (3)  Hiss  and  Russell  bacilli  attack  glucose  and 
mannite.     Xo  action  on  dextrin  and  lactose." 

Park  has  described  a  bacillus  which  produces  indol  in  a  peptone 
solution  and  differs  from  the  Shiga  in  its  agglutinating  characteristics, 
and  is  distinguishable  from  the  Flexner  organism  in  other  ways. 

The  progress  now  being  made  in  intestinal  bacteriology^  indicates 
that  ere  long  other  bacilli  concerned  in  the  causation  of  true  dysenteries 
and  the  summer  diarrheas  of  infants  and  children  will  soon  be  dis- 
covered, as  well  as  the  means  by  which  the  various  organisms  can  be 
clearly  distinguished  from  each  other. 

The  infection  of  animals  with  supposedly  dysenteric  bacilli  as  a 
confirmative  diagnostic  measure  has  thus  far  proved  disappointing 
and  unreliable. 

Manifestations  closely  resembling  those  of  bacillary  colitis  are  also 
encountered  in  hemorrhagic,  diphtheric,  and  catarrhal  affections  of  the 
colon,  and  in  ptomain,  mercurial,  and  bacterial  poisoning  acting  through 
the  blood.  Toxemias  may  also  be  induced  by  pathogenic  accidental 
and  obligate  intestinal  micro-organisms,  such  as  the  colon,  pyocyaneus, 
proteus,  and  acrogenes  bacilli,  streptococci,  and  staphylococci  when  they 
are  unduly  virulent  there  are  intestinal  lesions,  and  the  patient's 
resistance  has  been  lowered,  or  he  has  stomatitis,  angina,  pneumonia, 
or  sepsis. 


DIAGNOSIS  41 1 

The  blood  changes  of  l)acillar\-  eolith,  rescnihle  those  of  typhoid. 
in  that  there  is  an  absence  of  pohnuclear  leukocytosis  and  a  sUght 
lymphocytosis  in  the  beginning,  which  diminishes  to  the  normal  in 
from  a  week  to  ten  da\s. 

Kruse.  who  regards  his  bacillus  as  being  in  the  same  class  with 
Shiga's,  maintains  that  it  can  be  differentiated  from  pseudobacilli 
(Flexner,  Hiss,  Park,  etc.)  when  cultures  are  made  with  the  litmus- 
mannite  culture-media  of  Lentz,  and  because  his  and  the  Shiga  bacilli 
form  a  soluble  toxin  in  analogy  with  the  diphtheria  bacillus  in  contra- 
distinction to  the  others. 

The  agglutinating  is  the  most  reliable  test  for  detecting  bacillary 
colitis,  though  the  finding  of  the  bacilli  in  the  stools  or  other  organs 
after  death  points  strongly  to  them  as  the  cause  of  infection.  In 
the  Danvers  epidemic  this  test  proved  positive  in  the  first  week  in  50  per 
cent. ;  in  the  second,  in  92  per  cent.,  and  in  the  third  and  fourth  weeks  in 
100  per  cent,  of  the  cases.  The  conclusions  regarding  the  value  and 
variations  of  the  agglutinating  test  for  dysenteric  bacillary  colitis 
arrived  at  by  Richards,  Peabody,  and  Canavan,^  who  had  frequent 
occasion  to  apply  it  during  the  Danvers  Hospital  epidemics,  are  clearly 
emphasized  in  their  report,  viz.: 

"(i)  Sera  of  115  dysenteric  patients  were  tested  for  aggluiinaiion 
with  stock  cultures  of  the  Shiga  and  Flexner-Harris  types  of  Bacillus 
dysenterige.  Eighty-one  per  cent,  of  these  sera  gave  positive  agglutina- 
tion reactions,  in  the  sense  that  they  reacted  with  Shiga  (32  cases). 
with  Flexner-Harris  (37  cases),  or  with  both  (24  cases)  were  negative. 

"(2)  Ten  control  sera,  from  persons  without  obtainable  history  of 
dysentery,  proved  negative  except  in  one  instance  (positive  with  the 
Flexner-Harris  type,  -^). 

"(3)  A  positive  reaction  was  obtained  in  i  case  of  4  tested  on  the 
first  day  of  symptoms,  in  52.6  per  cent,  of  all  cases  (19)  tested  during 
the  first  week,  and  in  92.3  per  cent,  of  cases  (13)  tested  during  the  sec- 
ond week.  The  cases  (19)  tested  during  the  third  and  fourth  weeks 
after  onset  were  all  positive  to  Shiga,  Flexner-Harris,  or  both.  The 
percentages  of  positive  reactions  during  subsequent  weeks  declined 
somewhat  gradually. 

"(4)  The  serum  of  a  case  showing  the  Shiga  type  on  culture  may 
agglutinate  in  higher  dilution  a  stock  Flexner-Harris  type  than  a  stock 
Shiga  type.  One  serum  from  a  case  whose  stools  yielded  the  Park-Hiss 
type  of  Bacillus  dysenterige  in  this  epidemic  failed  to  agglutinate  the 
stock  cultures  of  either  Shiga  or  Flexner-Harris. 

"(5)  Analysis  of  the  table  of  agglutinations  shows  that  there  was  a 
sharp  increase  in  the  number  of  cases  with  sera  agglutinating  the  Shiga 
type  (14),  as  compared  with  the  sera  agglutinating  the  Flexner-Harris 
type  (7),  during  the  first  two  weeks  in  August,  corresponding  with  the 
highest  elevation  in  point  of  morbidity.  The  cases  arising  during  other 
weeks  are  either  too  few  for  deductions  or  else  show  a  marked  prepon- 
derance of  Flexner-Harris  agglutinators.  It  is  possible,  but  cannot 
1  Boston  Med.  and  Surg.  Jour.,  p.  681,  November  11,  1909. 


412  BACILLARY    COLITIS.    DIARRHEA    IN 

be  proved,  that  the  first  prominence  in  the  cur\-e  (first  phase  of  epi- 
demic) corresponds  to  an  invasion  of  organism  of  the  Shiga  type,  where- 
as organism  of  the  mannite-fermenting  type  may  be  found  through- 
out the  epidemic.     This  point  should  be  considered  in  future  work. 

"(6)  Serial  agglutination  tests  were  carried  on  in  38  cases:  (i) 
During  disease  or  convalescence,  1908;  (2)  in  February.  1909;  and  (3) 
in  March,  1909.  The  cases  were  chosen  at  random  as  clinically  typical 
cases  of  dysenter\\  Only  i  of  the  38  cases  was  negative  in  all  three 
serial  tests.  This  high  percentage  (97  per  cent.)  of  positives  with 
employment  of  serial  tests  may  be  contrasted  with  the  percentage 
(81  per  cent.)  obtained  from  cases  tested  during  the  disease  alone. 
The  results  are  interesting  and  capable  of  several  explanations — such 
as  development  of  agglutinins(?),  persistence  of  organism  producing 
agglutinins  in  the  absence  of  symptoms(?),  reinfection (?),  crossed 
agglutinin  formation  (Bacillus  coli)(?). 

"(7)  Several  instances  occurred  in  the  several  tests  of  the  develop- 
ment of  agglutinins  for  Flexner-Harris  that  required  many  months  to 
recover  from  dysenten,'.  In  some  instances  these  agglutinins  were 
transient  (e.  g.,  present  in  Februan.',  absent  in  March).  Xo  instance 
of  de  novo  development  of  Shiga  agglutinins  (either  persistent  or 
transient)  was  obser\-ed  during  February-  and  March,  1909,  examina- 
tions. 

"(8)  Conclusions  5,  6,  and  7  point  with  some  probabilitv^  to  the 
hypothesis,  already  advanced,  that  the  Shiga  t\'pe  of  Bacillus  dysen- 
teriae  is  a  true  parasite,  whereas  the  other  (mannite-fermenting)  types 
are  frequently  normal  inhabitants  of  the  intestinal  tract." 

Finally,  in  acute  cases  of  bacillar\'  colitis  the  intestine,  when 
inspected  through  the  sigmoidoscope,  appears  highly  colored,  edem- 
atous, and  the  mucosa  is  broken  at  one  or  many  points  by  superficial 
erosions,  is  covered  by  a  whitish  fibrinous  membrane  with  hemorrhagic 
markings  or  involved  in  a  gangrenous  process,  but  in  chronic  dysentery 
numerous  ulcers  variable  in  size  are  frequently  seen.  UsualK-  the 
rectum  is  sensitive  to  digital  examination  and  the  bowel  feels  warm  or 
hot  to  the  finger,  particularly  during  the  acute  stages  of  the  disease. 


CHAPTER   XXXVI 

BACILLARY    COLITIS    ( BACILLARY    DYSENTERY,   ASYLUM 
DYSENTERY),  DIARRHEA   IN   (Concluded) 

TREATMENT 

PROPHYLACTIC,   SUPPORTIVE.   MEDICAL,    SERUM,    IRRIGATING  AND  LOCAL. 

SURGICAL 

The  symptomatic  is  about  the  same,  but  the  curative  treatment  of 
hacillary  differs  materially  from  that  of  entamebic  colitis  (dysentery). 
This  is  due  largely  to  the  feicts  that  the  former  is  decidedly  more 
acute,  is  accompanied  by  a  high  degree  of  toxemia  which  demands  im- 
mediate consideration,  and  the  disease  responds  quickly  to  sero- 
therapy. 

The  rational  treatment  of  bacillary  colitis  embraces  (a)  prophylactic 
precautions ;  {h)  supportive  therapeutics ;  (c)  internal  medication;  (d) 
serotherapy;  (e)  colonic  irrigatio7i;  and  (/)  surgical  measures,  but  all 
these  methods  of  treatment  are  not  required  in  every  case. 

Prophylactic  Treatment. — In  many  respects  the  prophylaxis  of  bacil- 
lary is  similar  to  that  of  entamebic  colitis  discussed  elsewhere.  In  Eng- 
land the  percentage  of  asylum  inmates  who  suffer  from  this  type  of  dys- 
entery is  great,  and  the  mortality  of  those  afflicted  is  about  25  per  cent. 
The  disease  is  not  so  common  or  fatal  in  our  prisons,  barracks,  and  insane 
asylums,  but  prevails  to  a  much  greater  degree  than  is  believed,  and 
when  once  it  appears  in  these  institutions  in  epidemic  form  it  is  likely 
to  reappear  many  times  after  being  apparently  stamped  out  unless  rigid 
precautions  are  taken  to  destroy  everything  which  might  be  infected, 
and  isolate  patients  who  are  carriers  of  Bacillus  dysenteries,  because  it  is 
not  known  under  what  conditions  and  how  long  these  organisms  may 
live  in  or  outside  of  man. 

To  prevent  the  infection  from  spreading,  dysenteric  patients  should 
not  be  permitted  to  go  from  one  ward  or  house  to  another,  use  the  same 
toilet,  or  handle  the  food,  water,  drinking-cups  or  dishes  of  healthy 
individuals,  or  sleep  with  them.  Due  precaution  should  be  taken 
to  see  that  drinking-water  and  the  food  is  properly  protected  against 
contamination,  and  that  the  stools  of  dysenteric  patients  are  thoroughly 
disinfected  and  flies  are  prevented  from  spreading  the  disease.  Pas- 
teurizing or  otherwise  protecting  milk  against  infection  is  most  im- 
portant during  the  summer  months,  and  more  particularly  when  it 
is  to  be  consumed  by  infants  and  children.  Finally,  cleanliness  from 
cellar  to  garret  must  be  enforced  in  the  i)resence  of  indi\idual  and 
epidemic  cases. 

413 


414  BACILLARY    COLITIS.    DIARRHEA    IX 

Supportive  Treatment. — Supportive  measures  are  not  so  universally 
imperative  in  bacillarv'  as  the\"  are  in  the  treatment  of  entamebic  colitis, 
because  properly  (serum)  treated  patients  recover  from  this  aftection 
before  they  have  become  greatly  emaciated,  anemic,  and  run  down  as 
the  result  of  persistent  diarrhea,  loss  of  blood,  and  mixed  infection. 
When,  however,  bacillan,'  dysentery-  becomes  chronic,  one  should  build 
up  the  patient's  health  as  much  as  possible  by  giving  him  nourishing 
food,  tonics,  and  having  him  exercise  mildly  in  the  sunshine,  but  with- 
out aggravating  the  symptoms. 

In  this  form  of  colitis  rest  in  the  house  and.  preferably,  the  bed 
is  imperative  during  acute  crises,  because  of  the  toxic  condition  and 
profound  illness  of  the  patient,  but  when  the  affection  is  chronic  this 
is  not  necessar\'  or  advisable,  except  during  exacerbations  of  the 
symptoms  and  where  it  has  been  demonstrated  that  getting  up  or 
exercising  augments  the  diarrhea,  mucus,  and  blood  in  the  stools. 

In  acute  virulent  bacillar\-  dysenten,-  regulation  of  the  diet  is 
important,  and  all  food,  excepting  milk  or  water,  should  be  dis- 
continued for  from  twenty-four  to  forty-eight  hours,  and  for  the 
next  two  or  three  days  the  diet  should  be  confined  to  liquids,  such 
as  milk,  whey,  broths,  soups,  expressed  beef-juice  and  meat  extracts, 
strained  gruels,  whites  of  eggs.  etc..  after  which  the  amount  of 
nourishment  may  be  increased  and  a  mixed  diet  gradually  permitted 
in  proportion  as  the  acute  symptoms  modify.  The  author  does  not 
believe  in  starving  or  confining  patients  afflicted  with  chronic  dys- 
enten,- to  a  liquid  or  semifluid  diet,  but  makes  a  practice  of  letting 
them  have  as  abundant  and  mixed  diet  as  they  can  take  care  of.  for 
these  sufferers  are  often  poorly  nourished,  anemic,  and  run  down. 
Many  times  he  has  taken  individuals  aliliicted  with  chronic  dysentery 
who  had  been  living  on  liquids  for  a  long  time  without  benefit,  and 
immediately  started  them  on  the  road  to  recovery'  by  prescribing  a 
generous  mixed  diet  and  keeping  the  bowel  clear  of  irritating  discharges 
and  feces.  This  aftection  is  confined  chiefly  to  the  colon,  and  does  not 
interfere  with  digestion  when  gastro-intestinal  peristalsis  is  arrested, 
which  can  be  accomplished  by  intestinal  irrigation  or  by  means  of 
oil  emulsions  which  contain  antiseptic  healing,  astringent,  or  sooth- 
ing drugs  according  to  indications.  In  the  absence  of  bowel-washing 
it  is  necessary  to  pay  a  great  deal  more  attention  to  the  diet. 

In  acute,  and  sometimes  chronic,  bacillan,'  colitis,  where,  as  a 
result  of  profound  toxemia,  loss  of  blood,  or  exhaustion  incident  to 
persistent  diarrhea,  pain,  or  tenesmus,  the  patient  becomes  extremely 
weak,  anemic,  nervous,  or  the  heart  falters,  the  temporary'  adminis- 
tration of  alcohol,  whisk\',  brandy,  wine,  or  strsxhnin  is  advisable 
to  brace  him  up;  tonics  such  as  arsenic,  strychnin,  iron  preparations, 
or  Russell's  emulsion  are  occasionally  indicated  until  he  has  been 
strengthened  and  the  dysenteric  symptom-complex  has  ceased  or 
been  grcath^  modified. 

Medical  Treatment. — The  medicinal  treatment  is  symptomatic, 
since  no  drug  has  been  suggested  which  acts  as  a  specific  for  this  affec- 


MEDICAL    TREATMENT  415 

tion,  though  a  few  authorities  maintain  thai  it  can  he  cured  by  ipecacu- 
anha when  properly  administered. 

At  the  outset  in  the  acute,  subacute,  and  chronic  forms  of  bacillary 
dysentery  the  treatment,  of  whatever  kind,  should  be  inaugurated  by 
thoroitiihly  cleansing  the  bowel  of  tissue  debris,  discharges,  scybala, 
and  fluid  feces  by  the  administration  of  liberal  and,  if  necessary, 
repeated  doses  of  castor  oil,  5j  to  ij  (30.0-60.0),  magnesium  or  sodium 
sulphate,  5j  to  viij  (4.0-30.0),  or  calomel,  gr.  ij  to  iij  (0.12-0. 18). 

Unquestionably,  ipecac  is  the  most  generally  employed  and  useful 
remedy  that  we  have  for  this  affection,  because  its  administration 
nearly  always  diminishes  the  number  of  evacuations,  minimizes  pain 
and  tenesmus,  and  lessens  the  amount  of  pus  and  l)lood  in  the  stools. 
While  it  cannot  be  denied  that  the  drug  brings  about  these  beneficent 
results  in  many  instances,  the  fact  remains  that  ipecac  neither  destroys 
specific  bacilli  in  the  dejecta,  prevents  relapses,  nor  affects  a  perma- 
nent cure. 

The  best  results  are  obtained  from  ipecac  when  45  gr.  (3.0)  are 
administered  the  first  night,  and  the  amount  thereafter  is  decreased 
5  gr.  (0.30)  daily  until  10  gr.  (0.60)  are  given,  an  amount  which 
may  be  continued  nightly  until  the  dysenteric  symptoms  abate  or 
cease.  The  value  of  the  drug  may  be  enhanced  by  having  the  patient 
rest  quietly  in  a  darkened  room,  take  a  liberal  dose  of  castor  oil,  calo- 
mel, or  salts,  and  fast  for  a  few  hours  prior  to  its  administration  and 
remain  inactive  and  take  but  little  food  for  a  time  thereafter.  When 
the  medicine  induces  persistent  nausea  and  vomiting  this  may  be 
minimized  by  placing  a  mustard-plaster  or  ice-bag  over  the  stomach, 
lessening  the  doses  or  increasing  the  length  of  time  between  them,  and 
giving  the  drug  in  creatinized  or  chocolate-covered  pills  or  in  gelatin 
capsules.  In  subacute  and  chronic  bacillary  colitis  the  amount  of 
ipecac  administered  should  be  diminished  to  one-half  or  less  than  that 
recommended  above  for  the  acute  variety.  This  class  of  sufferers  at 
times  complain  bitterly  of  abdominal  pain,  cramps,  tenesmus  or  al- 
most incessant  evacuations,  and  often  collapse  unless  relieved,  which 
is  most  satisfactorily  accomplished  by  morphin,gr.  |  to  j  (0.008-0.015), 
hypodermically;  an  opiate  pill,  gr.  |  to  j  (0.008-0.015);  or  laudanum, 
Tipxx  (1.3),  alone  or  in  combination  with  belladonna,  gr.  |  to  j  (0.008- 
0.015),  when  enterospasm  is  a  complication. 

In  the  presence  of  persistent  active  fermentation  and  putrefaction, 
bismuth  subnitrate,  subcarbonate,  and  subgallate,  thymol,  beta-naph- 
thol,  salol,  and  like  remedies  in  10-  to  15-gr.  (0.60-1.0)  doses,  three 
times  daily,  assist  in  preventing  the  formation  of  gases,  minimizing 
bacterial  activity  and  modifying  the  dysenteric  symptoms,  and  similar 
benefits  are  derived  from  an  acidified  acetozone  solution,  1 13000,  when 
it  is  consumed  daily  in  amounts  not  to  exceed  i  or  2  quarts  (liters). 
Antiseptic  remedies  of  this  class  jirobabK'  possess  some  germicidal 
power,  but  if  they  should  be  administered  in  doses  of  sufficient  size  to 
kill  the  dysenteric  bacilli  death  would  ensue  from  poisoning.  Bis- 
muth  preparations,   administered  in   successixe  and   large  doses   (30 


4l6  BACILLARY    COLITIS,    DIARRHEA    IN 

gr.  or  more),  several  times  daily,  undoubtedly  lessen  the  number  of 
evacuations  for  a  time,  but  later  increase  them,  because  it  becomes 
impacted  in  ulcers,  acts  as  a  constant  source  of  irritation  or  accu- 
mulates in  the  form  of  hen's-egg-sized  enteroliths  or  larger  putty-like 
masses,  and  is  retained  to  block  or  traumatize  the  already  sensitive 
bowel.  Consequently,  this  drug  should  not  be  long  employed  in  the 
symptomatic  treatment  of  this  and  other  forms  of  ulcerative  colitis. 

Astringent  remedies,  gallic  acid,  tannalbin,  tannigen,  and  the 
salicylate  of  guaiacol,  given  in  lo-gr.  (0.60)  doses  three  times  daily, 
may  be  prescribed  in  urgent  cases  with  the  idea  of  modifying  or  con- 
trolling the  diarrhea,  but  are  useless  as  curative  agents.  Patients 
suffering  from  bacillary  colitis  would  have  their  symptoms  modified 
sooner  and  be  cured  more  quickly  if  physicians  would  substitute  sero- 
therapy and  intestinal  irrigation  for  the  old-time  remedies  so  often 
mistakenly  prescribed  for  this  condition. 

Serum  and  Vaccine  Treatment. — The  usefulness  of  dysenteric  sera  in 
the  treatment  of  bacillary  colitis  has  been  thoroughly  proved,  and  they 
are  as  necessary-  for  the  cure  of  this  disease  as  antitoxin  is  for  diphtheria. 
Their  employment  is  imperati\'e  because  they  effectively  relie\e  or 
cure  this  t>pe  of  dysenten.-  without  danger  of  causing  local  or  consti- 
tutional disturbances  or  leaving  annoying  sequelae.  Properly  pre- 
pared sera  shorten  the  attack  by  half,  immediately  modify  or  arrest 
the  dysenteric  manifestations,  and  the  subcutaneous  injection  of  the 
serum  is  usually  followed  by  recover^^  in  mild  cases  in  from  two  to  three, 
in  severe  cases  in  from  three  to  four,  and  in  grave  cases  in  from  four  to 
six  days,  but  when  the  serum  is  not  sufficiently  powerful  or  the  patient 
does  not  readily  respond,  more  than  one  injection  and  from  seven  days 
to  two  weeks  may  be  required  to  bring  about  the  cure,  owing  to  the 
influence  of  the  patient's  age  (thirty  to  fiity  years  being  favorable) 
and  resistance. 

This  treatment  is  not  so  effective  when  the  subject,  in  addition  to 
dysentery,  suffers  from  lues,  tuberculosis,  or  other  infectious  or  wast- 
ing disease,  and  convalescence  can  be  hastened  by  having  the  patient 
remain  quietly  in  bed,  consume  fluid  and  non-irritating  foods,  and 
wash  out  the  bowel  daily  with  bland  mild  astringent  or  antiseptic 
solutions,  except  where  experience  demonstrates  that  irrigation  is 
harmful. 

Bacillary-  dysenten*-  rarely  passes  into  the  chronic  state  and  relapses 
are  unusual  following  the  serum  treatment,  and  where  subsequent 
attacks  occur  they  are  mild,  far  apart,  and  are  easily  and  quickly 
controlled  by  repeating  the  injection.  Since  the  serum  is  harmless, 
and  tends  to  relieve  present  and  prevent  future  attacks,  the  author 
considers  it  advisable  to  continue  administering  it  at  internals  of  two 
or  three  days  or  longer,  according  to  indications,  over  a  period  varying 
from  two  to  eight  weeks  in  patients  apparently  cured,  with  the  idea 
of  forestalling  possible  future  trouble,  and  to  repeat  the  injections  at 
shorter  intervals  in  those  who  suffer  severely  from  colic,  hemorrhages, 
diarrhea,  or  toxic  manifestations. 


SERUM    AND    VACCINE    TREATMENT  417 

A  positive  diagnosis  of  bacillar\-  colitis  should  be  made  before  the 
serum  is  employed,  because  it  is  useless  in  the  treatment  of  enlamebic, 
halantidic,  helminthic,  coccidic,  ciliale,  and  flagellate  dysenteries. 

It  is  also  necessary  to  isolate  the  causative  organism  in  bacillary 
colitis,  since  a  serum  which  is  curative  in  the  presence  of  an  infection 
induced  by  the  Shiga  or  Kruse  bacilli  does  not  always  accomplish  the 
desired  result  when  the  dysentery  is  incited  by  organisms  of  the 
Flexner,  Park,  Duval,  and  Hiss  types.  It  is  also  important  to  deter- 
mine whether  or  not  bacillary  is  complicated  by  entamebic,  helminthic, 
or  other  form  of  dysentery,  and  if  there  is  mixed  infection  participated 
in  by  pathogenic  intestinal  micro-organisms,  because  thus  far  no  serum 
has  been  discovered  which  would  bring  al)()ut  complete  relief  under 
such  circumstances. 

Shiga  first  and  others  since  have  succeeded  in  producing  reliable 
dysenteric  sera  by  isolating  bacilli  responsible  for  colitis  and  injecting 
them  subcutaneously  or  into  the  veins  of  horses,  rabbits,  goats,  and 
other  animals.  Serum  obtained  from  animals  immunized  in  this  way 
has  a  decided  antibactericidal  action.  Todd  and  Rosenthal  succeeded 
in  obtaining  a  soluble  toxin  from  cultures  of  the  Shiga  and  Kruse  bacilli, 
with  which  he  immunized  animals  and  produced  a  serum  possessing 
decidedly  aw///o.v/c  powers.  Vaillard  and  Dopter,  using  this  discovery, 
immunized  horses  by  inoculating  them  on  alternate  weeks  with 
progressive  doses  of  living  bacilli  and  bacterial  toxins,  and  in  this 
way  obtained  a  serum  having  both  antibactericidal  and  antitoxic 
qualities. 

Attempts  have  been  made  to  produce  a  serum  which  would  prove 
effective  in  all  types  of  bacillary  dysentery  and  in  the  presence  of  a 
mixed  infection  by  immunizing  animals  with  cultures  of  the  Shiga, 
Kruse,  Flexner,  Park.  Du\'al,  Hiss,  colon,  and  other  bacilli,  but  the 
results  have  been  disappointing.  Serum  prepared  from  either  the 
Shiga  or  Kruse  organisms  is  effective  in  the  treatment  of  colitis  induced 
by  either,  and  is  helpful  in  other  forms  of  bacillary  dysentery,  but  the 
serum  from  animals  immunized  by  cultures  of  the  Flexner,  Duval, 
Park,  Strong,  or  Hiss  bacilli,  etc.,  will  not  relieve  or  cure  a  bacillary 
colitis  consequent  upon  the  first-named  organisms,  consequently  it  is 
advisable  to  use  in  the  individual  case  a  serum  derived  from  the  type  of 
bacilli  causing  the  dysentery. 

Like  other  therapeutic  agents,  the  amount  of  serum  prescribed 
must  be  varied  according  to  its  strength,  the  age  of  the  patient,  and 
his  resistance. 

The  serum  is  usually  administered  subcutaneously,  and  20  c.c.  is 
the  dose  ordinarily  given  to  adults,  but  half  this  amount  is  required 
for  children,  though  occasionally  a  smaller  quantity  will  suffice.  In 
mild  cases  one  injection  is  effective,  in  severe  ones  the  treatment  should 
be  repeated  in  six  hours,  and  in  grave  cases  the  injections  may  be  made 
twice  daily  for  two  or  three  days  or  until  the  patient's  condition  is 
markedly  improved.  When  he  is  dangerously  ill  from  hypertoxicity 
or  other  evidence  of  the  infection,  from  40  to  60  c.c.  or  more  may  be 
27 


41 8  BACILLARY    COLITIS,    DIARRHEA    IN 

administered,  and  the  injections  repeated  on  the  following  day  when 
indicated. 

The  serum  treatment  is  most  useful  when  employed  early,  and 
should  be  instituted  not  later  than  the  third  day  if  a  diagnosis  has 
been  made  and  the  serum  can  be  obtained. 

When  the  serum  is  used  in  time  the  mortality  of  bacillary  colitis 
is  from  33  to  50  per  cent,  less  than  when  other  methods  of  treatment 
are  practised,  and  Kruse  with  it  reduced  the  mortality  of  summer 
diarrhea  from  15  to  5  per  cent.  The  remarkably  good  results  of  the 
serum  treatment  are  shown  in  the  accompanying  summary  of  the 
96  cases  of  bacillary  dysentery  treated  by  Vaillard  and  Dopter,  viz.: 

Stools  in  twenty-four  hours.  Xumber  of  cases.  Deaths. 

1.  Ordinary  cases 15  to    20  50  o 

2.  Severe  cases 30  to    80  18  o 

3.  Grave  cases 80  to  150  24  o 

4.  Very  grave  cases 150  to  288  4  i 

Permanent  Immnnity.- — Dysenteric  (bacillan,-)  sera  will  relieve  or 
cure  bacillary  colitis  and  tend  to  prevent  relapses  and  reinfection 
when  the  patient  has  had  several  injections,  because  under  such  cir- 
cumstances antibodies  form  more  readily,  which  partially  immunize 
the  patient.  Thus  far  no  bacillary  produced  vaccine  has  been  brought 
out  which  when  injected  permanently  insures  against  infection  from 
all  the  types  of  dysenteric  bacilli.  Shiga  at  one  time  practised  mixed 
active  and  passive  immunization  (bacilli  plus  immune  serum  on  10,000 
individuals),  but  this  did  not  decrease  the  number  of  infections,  al- 
though a  lower  mortality  was  obtained. 

Good  results  have  been  reported  from  combined  vaccine  and  serum 
therapy,  but  from  what  has  been  said  it  may  be  inferred  that  these 
agents  are  more  curative  than  preventive  as  regards  bacillary  colitis 
(dysentery). 

Irrigating  and  Local  Treatment. — Irrigation  and  topical  applications 
are  indicated  often  in  bacillary  colitis,  but  they  are  not  as  necessary 
here  as  in  the  treatment  of  entamebic  dysentery,  because  the  former 
frequently  responds  to  sera  and  less  often  passes  into  the  chronic 
ulcerative  state,  and  for  the  reason  that  in  this  affection  the  mucosa  is 
so  very  irritable  and  sensitive  that  irrigating  solutions  are  frequently 
expelled  before  they  have  accomplished  their  purpose,  or  when  re- 
tained do  more  harm  than  good,  except  where  the  mucosa  is  exten- 
sively ulcerated. 

The  technic  of  using  and  the  solutions  employed  in  bacillary  are  the 
same  as  those  already  given  for  entamebic  colitis,  except  that  their 
strength  should  be  weaker  in  all  but  the  chronic  form  of  the  disease, 
where  ulceration  is  extensive  and  mixed  infection  is  evident.  Con- 
sequently, silver  nitrate,  thymol,  potassium  permanganate,  protargol, 
argyrol,  and  acetozone,  in  strengths  varying  from  i  :  2000  or  3000, 
are  to  be  recommended  in  this  class  of  cases  during  the  acute  and 
subacute  stages,  and  stronger  in  long-standing  cases.     The  duration 


IRRIGATING    AND    LOCAL    TRI<:ATMIiNT  419 

of  the  irrigations  and  tlicir  livquency  must  he  varied  to  meet  the  indi- 
cations or  be  (Hscontinued  when  they  fail  to  minimize  the  infection, 
modify  the  s>-mptoms,  make  the  patient  extremely  nervous,  or  aggra- 
vate the  dysenteric  symptom-complex. 

Soothing  remedies  usually  accomplish  more  and  in  a  shorter  time 
than  cauterization,  astringents,  or  stimulation.  The  most  useful  agents 
for  diminishing  intestinal  irritability,  quieting  peristalsis,  and  minim- 
izing the  frequency  of  the  evacuations  are  warm  or  hot  crude  petro- 
leum, coal  oil,  liquid  paraffin,  or  olive,  sweet,  almond,  or  mineral  oil 
(liquid  petroleum)  injected  in  liberal  amounts,  5ij  to  vj  (60.0-180.0), 
at  night,  and  allowed  to  remain  until  morning  or  longer,  following 
washing  out  of  the  bowel  with  a  normal  saline  solution.  Irrigants  of 
strained  gruels,  flaxseed  tea,  slippery-elm  bark,  or  starch-water  and 
mild  boric  acid  solutions  are  also  comforting  and  healing.  In  the 
presence  of  extreme  intestinal  irritability  the  nightly  injection  of  from 
5iij  to  iv  (90.0-120.0)  of  the  following  emulsion  quickly  brings  relief: 

Bf,     ( )livc  oil Oj  (500.0) ; 

Orthoform 5  j  to  ij  (4.0-8.0) ; 

Bismuth  sub.  nit 5  j  (30.0). — M. 

Ft.  emulsion. 
Sig. — Warm,  shake,  and  inject  ,*ij  to  vj  (60.0-180.0)  at  night. 

Solutions  and  oils  should  be  used  warm  or  hot  because  of  the  sooth- 
ing effect  of  the  heat,  and  not  cold,  because  enemata  and  irrigations 
having  a  low  temperature  often  incite  enterospasm  and  are  promptly 
expelled.  For  reasons  given  elsewhere  it  is  impossible,  as  a  rule,  to  in- 
sert a  colon-tube  beyond  the  middle  sigmoid  (see  Fig.  16),  and,  owing 
to  this,  and  because  fluids  introduced  into  the  rectum  by  means  of  a 
short  tube  or  irrigator  can  be  made  to  reach  all  parts  of  the 
colon  W'hen  the  patient  is  in  the  Sims  or  lithotomy  postures  with  the 
hips  elevated,  the  employment  of  lengthy  pipes  is  to  be  discounte- 
nanced for  irrigating  purposes.  Long  tubes  arp  also  objectionable 
because  they  frequently  kink,  induce  considerable  pain,  or  ma\'  per- 
forate the  intestine  when  it  is  ulcerated. 

Oils  and  emulsions  can  be  injected  by  means  of  a  Da\-idson  or 
fountain  syringe,  but  a  piston  syringe  is  preferable,  because  with  it  the 
necessary  force  can  be  used  at  the  right  time,  since  oil  preparations  are 
thick  and  difficult  to  propel  and  readily  spoil  the  valves  or  rot  the 
tubing  of  other  syringes. 

When  oil  treatments  are  being  made  by  the  attending  physician 
the  patient  should  be  placed  in  the  inverted  posture  (see  Fig.  122),  the  ■ 
proctoscope  introduced,  gas  permitted  to  escape,  and  the  warm  sooth- 
ing oil  or  emulsion  should  be  poured  directly  into  the  upper  rectum  or 
sigmoid  flexure,  from  whence  it  immetliately  makes  its  way  around  the 
colon  to  the  cecum;  but  when  it  does  not,  this  can  be  accomplished  by 
massaging  the  colon  or  changing  the  patient's  posture. 

Soothing  are  useful,  but  stimulating  topical  applications  do  more 
harm  than  good  in  all  but  cases  of  chronic  bacillary  colitis  with  ulcera- 


420  BACILLARY    COLITIS,    DIARRHEA    IX 

tion.  Consequenih-,  the  Paquelin  electric  and  chemic  cauteriza- 
tions are  contra-indicated  except  in  the  presence  of  mixed  infection 
and  old  ulcers  that  are  not  benefited  by  less  radical  measures.  Rec- 
tosigmoidal  irritability  can  be  materially  reduced  and  dysentery  mark- 
edly improved  by  mopping  the  inflamed  mucosa,  erosions,  or  ulcers 
with  warm  oil,  sedative  oil  emulsions,  methylene-blue  (lo  per  cent.), 
or  extremely  mild  preparations  of  silver,  3  per  cent.;  ichthyol,  6  per 
cent.;  balsam  of  Peru,  10  per  cent.;  protargol  or  argyrol,  5  per  cent., 
two  or  three  times  weekly  after  the  bowel  has  been  washed  out  with 
a  normal  saline  solution. 

In  making  topical  applications  extreme  caution  is  necessary,  other- 
wise injury  caused  by  introduction  of  the  proctoscope  or  sigmoido- 
scope through  which  they  are  to  be  made  will  counterbalance  the  good 
elTect  of  the  medication.  Specula  should  never  be  employed  for  this 
purpose  because  the>"  traumatize  the  rectum  and  induce  much  un- 
necessary pain. 

Surgical  Treatment. — Surgical  measures  are  rarely  required  in  the 
treatment  of  bacillary  colitis  (dysentery)  properly  treated  because  it  is 
curable  by  serotherapy  alone  or  when  supported  by  colonic  irrigation. 
In  neglected  cases,  and  where  the  patient  has  been  badly  handled  and 
the  disease  has  become  chronic,  mixed  infection  prevails,  numerous 
large  deep  ulcers  have  formed,  extensive  sloughing  of  the  mucosa  has 
occurred,  or  strictures  have  resulted  from  the  healing  of  raw  areas,  and 
when  hygienic  measures,  dieting,  medication,  serotherapy,  and  irri- 
gation from  below  fail  to  effect  a  cure,  appendicostomy  (see  Fig.  164), 
cecostomy  (see  Fig.  155),  Ganfs  enterocecostomy  (see  Fig.  156)  (which 
provides  a  means  of  simultaneously  or  separately  irrigating  the  small 
and  large  intestine),  enterostomy,  colostomy,  resection,  or  amputation  are 
indicated.  Of  these  procedures,  the  first  three  are  frequently  and  the 
remainder  are  seldom  required  in  the  treatment  of  this  condition. 

Their  advantages  and  disadvantages  need  not  be  discussed  here  be- 
cause they  have  received  due  consideration  in  the  chapters  devoted  to 
the  surgical  treatment  of  entamehic,  which  is  practically  the  same  as 
that  of  bacillary  colitis,  and  the  technic  of  these  operations  has  been 
fully  described  in  the  chapters  on  the  Surgical  Treatment  of  Diarrhea. 

Overmuch  cannot  be  said  regarding  the  importance  of  through- 
and-through  irrigation,  as  one  is  enabled  to  practice  it  following  ap- 
pendicostomy, cecostomy,  and  the  author's  enterocecostomy. 

The  irrigants,  medicated  solutions,  oils,  and  emulsions  indicated 
in  bacillary  are  the  same  as  those  employed  in  the  irrigating  treatment 
of  entamebic  colitis,  to  which  the  reader  is  referred.  It  is  essential  that 
the  solution  should  be  warm  and  abundant,  and  be  permitted  to  run 
freely  through  the  colon  and  out  of  the  rectum  through  a  proctoscope 
until  the  bowel  is  thoroughh-  cleansed  of  offensive  discharges,  toxins, 
and  feces,  and  that  during  the  irrigation  the  position  of  the  patient 
be  changed  from  time  to  time  to  make  sure  that  the  solution  comes  in 
contact  with  all  lesions  on  all  sides  and  along  the  entire  course  of  the 
infected  intestines. 


SURCilCAL    TREATMENT  42  I 

Frequently  the  appendix  affords  a  lodging-place  for  dysenteric 
bacilli  and  the  patient  repeatedly  suffers  from  reinfection,  and  in 
such  cases  appendectomy  is  indicated  in  connection  with  cecostomy 
and  after  appendicostomy  following  a  cure. 

Artificial  openings,  eslablished  with  the  idea  of  facilitating  through- 
and-through  drainage,  should  not  be  closed  until  long  after  all  dysen- 
teric bacilli  have  disappeared  from  the  stools,  because  early  closure  is 
often  followed  by  relapses. 

In  suitable  cases  surgical  measures,  reinforced  by  effective  irriga- 
tion, frequently  enable  one  in  a  short  time  to  cure  patients  who  have 
been  treated  for  months  or  years  without  benefit  by  dieting,  internal 
medication,  and  attempts  at  irrigation  from  below,  and  the  author  feels 
that  he  cannot  recommend  appendicostomy  and  cecostomy  too  strongly 
in  this  class  of  cases. 


CHAPTER  XXXVII 

HELMINTHIC    COLITIS   (PARASITIC  COLITIS),   HELMINTHI- 
ASIS,  HELMINTHIC    DYSENTERY,   DIARRHEA   IN 

CESTODES,  NEMATODES,  TREMATODES  (TENIASIS,  UNCINARIASIS, 
HOOKWORM  DISEASE),  ASCARIASIS,  OXYURUSIS,  TRICHURIA- 
SIS (TRICOCEPHALIASIS),  SCHISTOSOMIASIS,  TRICHINIASIS 

Helminthiasis  induced  by  worms  and  fluke-worms  is  frequently 
complicated  by  chronic  diarrhea,  abdominal  pain,  and  blood  in  the 
stools  independently  and  when  associated  with  entamebic  or  bacillary 
colonic  infection.  Helminthic  colitis  is  frequently  encountered  in 
tropical  and  semitropical  countries,  has  occasionally  been  met  with 
in  the  States,  and  is  said  to  be  the  cause  of  Cochin-China  diarrhea, 
which  kills  thousands  of  Chinese  yearly. 

When  considering  helminthic  diarrhea  (dysentery)  it  is  well  to 
bear  in  mind  that  increased  movements  incited  by  worms  in  the 
intestine  do  not  always  result  from  colitis  (catarrhal  or  ulcerative), 
for  they  may  be  induced  by  exaggerated  peristaltic  activity  or  glandular 
hypersecretion  where  helminths  cause  local  irritation  without  lesions, 
or  make  the  patient  nervous,  which  leads  directly  or  indirectly  to 
digestive  disturbances,  intestinal  irritability,  and  loose  movements. 

Where  helminths  are  detected  in  the  stools  in  connection  with 
entamebae  (histolytica)  or  dysenteric  bacilli  (Shiga's,  Flexner's,  etc.) 
in  patients  suffering  from  diarrhea  a  diagnosis  of  entamebic  or  bacillary 
colitis  is  justified,  because  when  either  infection  is  manifest  it  is  more 
likely  responsible  for  the  frequent  fluid  and  bloody  evacuations  than 
worms. 

Helminthiasis  is  as  frequently  characterized  by  constipation  as 
diarrhea,  and  in  some  instances  the  patient  suffers  from  alternating 
loose  movements  and  obstipation. 

Active  intestinal  worms  may  induce  obstipation  by  forming  ball- 
like masses  and  blocking  the  bowel  (see  Fig.  88),  or  by  causing  local 
irritation  and  inciting  the  simultaneous  contraction  of  the  circular  and 
longitudinal  muscular  fibers,  thus  producing  enterospasm  and  spastic 
constipation. 

In  so  far  as  the  symptoms  are  concerned,  there  is  not  a  great 
deal  of  difference  between  entamebic,  bacillic,  and  helminthic  colitis 
(dysentery),  and  because  of  this  a  thorough  macroscopic  and  micro- 
scopic examination  of  the  dejecta  is  necessary  in  suspected  cases  to 
clear  the  diagnosis. 

The  author  has  no  intention  of  going  deeply  into  helminthology, 
422 


CESTODES    (tapeworms) 


423 


since  his  object  here  is  to  show  the  relation  of  intestinal  worms  to 
diarrhea,  call  attention  to  the  similarity  in  the  symptoms  of  enta- 
mebic,  helminthic,  and  bacillic  colitis,  briefly  outline  the  methods  of 
differentiating  one  from  the  other,  and  summarize  the  salient  features 
in  the  treatment  of  helminthiasis  complicated  by  diarrhea. 

In  so  far  as  they  relate  to  diarrhea  and  colitis  (dysentery),  intes- 
tinal helminths  (worms)  may  be  grouped  under  three  headings: 

(i)  Cestodes  (flat  worms). 

(2)  iV(?ma/w/e,s-  (round- and  thread-worms).  , 

(3)  Trematodes  (fluke-worms). 

CESTODES   (TAPEWORMS) 

Tapeworms  are  long,  fiat,  segmented,  of  a  whitish  color,  and  vary 
greatly  in  width  and  length.  Of  the  many  varieties  parasitic  in  man 
the    Tcenia   solium   (pork  tapeworm),    T.  saginata   (beef  tapeworm), 


Excretory  canal 


Uterus. 


Vas  deferens 


-Genital  pore 


Vagina 


Fig.  74. — Taenia  solium,  gravid  segment.     (Original.) 

T.  lata,  Bothriocephalus  latus  (fish  tapeworm),  and  T.  nana  (dwarf 
tapeworm)  are  the  tyjies  most  frequeiUK-  responsible  for  diarrhea  and 
other  intestinal  disturbances. 

TcBnia  Solium  (Fig.  74). — This  parasite,  usually  designated  as  the 
pork  or  armed  tapeworm,  varies  from  6\  to  13   feet   (2-4  meters)  in 


424 


HELMINTHIC    COLITIS    AND    DYSENTERY,    DIARRHEA    IX 


length,  has  800  to  900  segments,  and  a  small  spheric-shaped  head  about 
the  size  of  a  pinhead.  It  is  very  common  in  Germany  and  countries 
where  improperly  inspected  or  cooked  pork  is  freely  consumed,  and  is 
rarely  encountered  in  Jews  and  Mohammedans,  who  do  not  eat  hog 
meat. 

Cysticerci  exist  in  measly  pork,  and  when  eaten  uncooked  the  cyst 
wall  breaks  down  after  reaching  the  intestine,  and  this  permits  the 
contained  head  of  the  parasite  to  become  attached  to  the  mucosa,  from 
which  the  worm  develops  as  segments  form. 

Tccnia  Saginata  (Fig.  75). — -This  tapeworm  (beef),  the  most  com- 
mon of  all  in  America  and  throughout  the  w^orld,  is  unarmed  and 
considerably  longer,  thicker,  and  wider  than  the  Taenia  solium;  varies 
in  length  from  13  to  40  feet  (4-12  meters),  has  from  1000  to  3000  seg- 


Fig.  75.— Taenia  saginata.  Appearance  of  gravid  segment  without  magnification. 
Method  of  making  diagnosis  by  pressing  gravid  segment  between  two  glass  sUdes. 
(Original.) 


ments,  and  possesses  a  darkly  pigmented  cuboid-shaped  head  devoid  of 
booklets.  The  cysticerci  are  derived  from  raw  or  improperly  cooked 
beef  and  rapidly  develop  in  the  intestine,  segments  sometimes  appear- 
ing within  two  months  following  infection. 

Siler  holds  that  three  weeks'  cold  storage  destroys  cysticerci  so 
that  the  beef  cannot  infect  the  consumer.  Stiles  estimates  that 
Taenia  saginata  grow  13  segments  daily  and  produce  150,000,000  eggs 
in  a  year. 

Taenia  Lata,  Bothriocephalns  Latiis  (Fig.  76). — This,  or  the  fish 
tapeworm,  which  possesses  a  head  shaped  somewhat   like  that  of  a 


DIAGNOSIS  425 

pig,  is  ihe  longest  of  the  cestodes,  since  it  measures  from  6|  I0  32 
feet  (2-10  meters)  ordinarily,  and  exceptionally  65  feet  (20  meters)  in 
length,  and  is  composed  of  from  2000  to  4000  segments.  It  is  thin 
and  flat  or  ribbon-like,  but  its  central  segments  are  very  much  broader 
than  Taenia  solium,  V.  saginata,  or  T.  nana,  and  above  and  below  this 
point  they  gradualh'  become  longer  and  more  narrow.  The  segments 
grow  rapidly  in  the  bowel,  and  from  25  to  ^r^^-. 

30  are  produced  daily,  and  Siler  says  they  ^'''^•Sr  • 

are  discharged  in  chains  rather  than  singly. 

The    infection    is    derived    from    pike,  ,.; 

perch,  salmon,  and  other  fresh-water  tish,  y 

and   it  has  been  estimated  that  in  certain     /          ■  r 

sections  of  Japan   and   Turkestan  20  per  1^ Elongated  siit- 

cent.  of  the  inhabitants  are  infected.     This  like  sucker 

parasite  has  for  a  number  of  years  been  fre- 
quently encountered  in  Switzerland,  Ger- 
many, Russia,  Poland,  Holland,  Sweden, 
Madagascar,  and  South  Africa,  where  the 
eating  of  raw  fish  is  common. 

Tcenia  {Hymenolepis)  nana  (Figs.  77, 
78). — This  parasite,  because  of  its  small 
size,  is  called  the  dwarf  tapeworm;  form- 
erly it  was  believed  to  be  of  verv  rare  oc-     Fiff-   76.— Head    of    Bothrio- 

1     ^     •  o  '  ccphalus  latus.     (Original.) 

currence,  but  smce  1894,  50  or  more  cases  ^  ^     »       / 

have  been  reported.  It  has  also  been  encountered  in  Egypt,  Siam, 
Japan,  and  Italy,  where  Calandruccio  says  10  per  cent,  of  the  children 
are  infected  by  it. 

TcenicB  nana  are  very  fragile,  and  except  when  numerous  are 
often  overlooked  in  the  feces.  They  are  composed  of  from  100  to 
200  segments,  -i-  to  ij  inches  (5-35  mm.)  in  length,  and  the  sections, 
barring  those  at  the  tail,  are  broader  than  long.  The  eggs  after 
being  swallowed  find  their  way  to  lower  small  intestinal  villi. 

Practically  all  tapeworms  make  their  habitat  in  the  small  intes- 
tine, and  the  symptoms  and  methods  of  diagnosing  teniasis  are  some- 
what similar,  irrespective  of  the  type  of  worms  causing  the  trouble. 

Symptoms. — Tapeworms  in  the  intestine  may  cause  little  or  no 
inconvenience,  or  slight  or  marked  disturbances.  Patients  who  suffer 
from  chronic  frequent  evacuations  and  diarrhea  alternating  with 
constipation,  hunger,  and  complain  of  anorexia,  nausea,  vomiting,  itch- 
ing of  the  nose  or  anus,  colicky  pains  after  eating  sour  food,  convul- 
sions, palpitation,  hives,  hysteria,  and  tympanites  should  be  suspec- 
ted of  harboring  a  tapeworm.  The  eyes,  brain,  lungs,  kidneys,  and 
other  structures  remote  from  the  intestine  may  also  become  in\ol\ed 
by  cysticerci  or  larvcC  which  reach  ihem. 

Diagnosis. —  Teniasis  is  comparati\ely  easy  to  diagnose  when 
several  of  the  above-mentioned  typic  manifestations  of  the  disease  are 
present  and  the  stools  are  macroscopically  and  microscopicalK'  ex- 
amined, which  in  such  cases  reveal  the  whole  worm,  mature  segments, 


426 


HELMINTHIC    COLITIS    AND    DYSENTERY,    DIARRHEA    IN 


parasitic  ova,  or  Charcot-Leyden  crystals.  When  the  dejecta  do  not 
contain  samples  of  the  worm  or  its  eggs,  they  can  be  brought  down  for 
examination  by  the  administration  of  an  active  cathartic,  and  when 
found  ilu'  sjK'cics  to  which  they  belong  can  be  determined. 

Treatment  of  Teniasis. — The  prophylactic  treatment  consists  in 
not  eating  improperly  inspected,   raw,  or  underdone  pork,  beef,  and 

fresh-water  fish,  not  drinking  con- 
taminated water,  nor  sitting  on 
toilets  used  by  infected  persons. 

Sometimes  tapeworms  are  easy 
and  at  others  they  are  extremely 
difficult  to  expel.  When  a  patient 
is  ready  to  be  relieved  of  the 
worm,  first,  he  should  be  placed  upon 
a  fluid  diet  for  twenty-four  hours; 
second,  the  bowel  should  be  cleared 
of  feces  and  mucus  by  a  hydra- 
gogue  cathartic  (salts  or  calomel) ; 
third,  a   teniafuge  or  anthelminthic, 


Rostcllum 


Hooks 


.#■ 

<,  < 

■  '  . 

''A 

:1^' 

'? ' 

'■    '''-^^ 

Mature  sei 

/    '^-"^ 

ments 

'■^■er 

fe^^4 

I 

m^G 

ravid  si 

L;gmcilt 

h '  ' ' 

Fig.    77. — Taenia     (Hymenolepis) 
(Original.) 


Fig.    78.- 


-Hcad    of   Taenia  (Hymenolepis) 
nana.     (Original.) 


such  as  male  fern,  5ss  to  ij  (2.0-8.0);  pomegranate  root,  fluidextract, 
5ss  to  ij  (2.0-8.0) ;  pumpkin  seed  or  pelletierin,  gr.  v  to  vij  (0.30-0.50), 
should  be  administered  to  dislodge  the  parasite;  and  fourth,  a  purgative, 
castor  oil,  oj  (30.0),  or  a  liber^il  dose  of  calomel  followed  by  salts  should 
be  given  shortly  following  the  teniafuge  to  cause  expulsion  of  the  worm. 
The  dejecta  should  be  deposited  in  a  bed-pan  or  chamber  filled  with 
warm  water  and  the  parasite  permitted  to  come  away  unaided.  When 
it  is  thought  that  all  or  a  part  of  the  worm  has  been  expelled,  a  thor- 
ough examination  should  be  made  for  the  head,  which  when  found  indi- 
cates that  the  treatment  has  been  successful. 


ETIOLOGY  427 

When  cathartics  fail,  saline  enemata  will  occasionally  free  the  bowel 
of  the  parasite. 

The  treatment  is  very  severe  and  should  not  be  repeated  until 
several  weeks  have  elapsed,  so  that  the  patient  can  regain  his  strength 
and  the  mucosa  become  normal.  In  ver>^  obstinate  cases,  where  male 
fern  alone  does  not  prove  effective,  Cohnheim  recommends  the  follow- 
ing vermifuges: 

I^     Extract!  filicis  maris  jether gtt.  .xK-iij  to  Ix  (3.0-4.0) ; 

Chloroformi gtt.  vj  (0.36) ; 

Olei  ricini  )  __-./,, 

^ ,     -I     •   .  •     y aa  5 1  (30.0) ; 

Mucilaginis  acaciae  J  «jj  \o      /i 

AquiE  dcstillatze q.  s.  ad  S^^ss  (200.0). — M. 

Ft.  emulsio. 

Sig. — Introduced  through  a  stomach-tube  earl)'  in  the  morning. 

I^     Graniti  corticis 5j  to  iss  (30.0-50.0). 

Mac.  per  hor.  xii  cum  200-300  aq.  dest.  deinde  coque  ad  remanentiam.  150.0. 
Sig. — Drink  or,  preferably,  introduce  it  through  a  stomach-tube  early  in  the  morning. 

NEMATODES    'ROUND  OR   UNSEGMENTED  WORMS  1 

Nematode  worms  are  cylindric  in  form,  devoid  of  segmentation, 
and  are  variable  in  size  and  thickness.  The  more  common  parasites 
of  this  group,  while  frequently  encountered  in  America,  show  a  pref- 
erence for  tropical  climates,  where  in  some  sections  the  dejecta  of 
the  inhabitants  contain  one  or  the  other  forms  of  nematodes  or  their 
ova. 

Uncinariasis    Ankylostomiasis.  Hookworm  Disease.  Dirt- 
eaters*  Anemia  ,  Diarrhea  in 

Uncinariasis,  or  what  is  more  commonly  termed  hookworm  dis- 
ease, has  been  encountered  more  or  less  frequently  in  most  tropical 
and  temperate  climates,  but  the  affection  shows  a  prevalence  for  trop- 
ical regions  where  the  atmosphere  is  moist  and  the  soil  sandy. 

Intestinal  medicated  irrigation  is  useful  in  these  cases  when  the 
colonic  mucosa  is  inflamed  or  ulcerated  and  the  patient  suffers  from 
diarrhea. 

Etiology. — Ankylostomiasis  and  uncinariasis  are  caused  by  Xeca- 
tor  americanus  (Stiles,  1902)  or  Ankylostoma  diiodenale  (Dubini,  1838), 
small  worms  belonging  to  the  family  Strong>loidce.  The  former  is 
the  parasite  which  causes  the  trouble  in  this  countr\-,  and  the  latter, 
in  England  (Figs.  79,  80). 

The  Ankylostoma  diiodenale  (Fig.  79)  is  round,  %  inch  or  less  in 
length,  and  tapers  toward  the  posterior  extremity,  is  harbored  chiefly 
in  the  small  intestine,  particularly  in  the  jejunum  (less  often  in  the 
duodenum),  and  rarely  reaches  the  ileum  or  colon.  It  attaches  itself 
to  the  mucosa,  from  which  it  withdraws  the  blood  upon  which  it  feeds, 
and  leaves  oozing  spots  when  its  position  is  changed;  it  thrives  upon 
the  plasma,  and  red  blood-corpuscles  pass  through  it  undisturbed. 

Female  hookworms  (Fig.  82)  are  smaller,   but   three   times  more 


428  HELMINTHIC    COLITIS    AND    DYSENTERY,    DIARRHEA    IN 


Excretoo'  pore  —i 

1    /J 

ff    Esophagus 

Excretory 1 

pore      } 

r     Esophageal 
t~      gland 

^K^  Esophagus 
^■^^L- Intestine 

li 

—  Intestine 

^VflH^Cer\-icaI  gland 

- —  Testis 


Seminal  vesicle 


Spicules  — ^^ 
Fig.  79. — Male    Ankylostoma    duodenale. 
(Original.) 


D 


Genital 
pore 


a'teri 


-Oviduct 


■  CK'ary 


Anus  • 

Fig.  80. — Female    Necator    americanus, 
lateral  \new.     (Original.) 


I 


Fig.  81. — Male  Necator  americanus,  nat-       Fig.  82. — Female  Necator  americanus,  nat- 
ural size.     (Original.)  ural  size.     (Original.) 


PROGNOSIS 


429 


//: 


\ 


common  than  males  (Fig.   81),  and  both   present  a  grayish   appear- 
ance when  empty,  or  brownish  when  cHstended  with  blood. 

The  Necator  americaniis,  the  chief  etiologic  factor  in  uncinariasis 
in  the  United  States,  is  shorter  and  more  slender  than  the  Ankylostoma 
duodenale,  which  it  closely  resembles,  but  in  this  species  the  female 
is  slightly  larger  than  the  male. 

Uncinariasis  or  ankylostomiasis  results  from  injection  by  the 
larvcB  of  the  Ankylostoma  duodenale  or  Necator  americaniis,  which  gain 
entrance  to  the  circulation  chiefly  through  the  skin,  from  whence  they 
are  carried  in  a  roundabout  way  to  the  small  intestine,  where  the\- 
develop;  may  also  be  con\e\-ed  directly  to  the  alimentary  tract  in  con- 
taminated water  or  food. 

Pathology. — The  pathologic  changes  induced  in  the  bowel  by  An- 
kylostoma duodenale  and  Necator  americaniis  vary  according  to  the 
magnitude  of  the  infection,  but  usu- 
ally there  is  a  congested  mucosa, 
dotted  over  with  hemorrhagic  spots, 
which  indicate  the  points  of  attach- 
ment of  the  hookworm  and  how  the 
loss  of  blood  responsible  for  the  an- 
emia occurs. 

Symptoms. — The  manifestations 
of  uncinariasis  are  mainly  those  of 
anemia  from  other  causes,  and  in 
severe  cases  the  patient  often  sulYers 
from  frequent  evacuations  or  diar- 
rhea, alternating  with  constipation, 
has  a  perverted  appetite,  and  rel- 
ishes dirt,  charcoal,  wood,   cloth,  etc. 

Children  afflicted  with  ankylosto- 
miasis or  uncinariasis  are  undevel- 
oped, adults  are  weakened,  have 
very  little  energy,  and  the  blood 
changes  vary  with  the  different  stages 
of  the  disease  and  severity  of  the 
infection,  but  in  a  general  way  they 
resemble  the  blood-picture  presented 

in  chronic  anemia.      Cardiac  disturbances,  difficult  breathing,  ascites, 
and  mental   incapacity  are  characteristic  in  old  and  neglected  cases. 

Diagnosis. — In  regions  where  hookworm  disease  is  endemic  the 
nature  of  the  trouble  should  be  suspected  in  all  anemic  patients  ha\- 
ing  a  perverted  appetite.  A  careful  examination  of  the  dejecta  and 
finding  of  either  the  adult  worms,  their  ova  (Figs.  84,  85),  or  Charcot- 
Leyden  crystals  is  necessary  to  complete  the  diagnosis. 

Prognosis. — In  Porto  Rico  it  is  said  that  one-third  of  the  deaths  are 
due  to  uncinariasis.  When  the  parasites  are  numerous  and  the  patient 
goes  untreated  the  disease  progresses  rapidly,  and  he  succumbs  to 
dropsy  and  heart  or   lung  complications,  but  when  the  infection  is 


Fig.  83.- 


-Head   of    Necator 
canus. 


430  HELMINTHIC    COLITIS    ANT)    DYSENTERY.    DIARRHEA    IN 

not  severe  the  sufferer  may  live  for  a  long  time  or  permanently  recover 
when  he  is  properly  treated  and  the  worms  and  their  ova  are  destroyed 
or  expelled. 

The  treatment  of  hookworm  disease  has  been  \er\-  gratif\ing 
where  thymol,  hcta-naphthol,  gr.  xv  (i.o),  or  eucalyptus  have  been 
employed,  but  of  these  therapeutic  agents  thymol  is  the  most  reli- 
able. To  obtain  the  best  results  with  this  drug  the  patient  should 
be  confined  to  a  liquid  diet  for  two  days  and  have  the  bowel  cleared 


.  \!? 


Fig.    84. — Egg    of    Xecator   americanus        Fig.  S5. — Egg  of  Xecator  americanus  em- 
developing  embrj-o.     (Original.)  br>-o  escaping  from  shell.     (Original.) 

by  a  saline.  On  the  next  morning  four  15-gr.  (i.o)  doses  of  thymol 
should  be  administered  one  hour  apart,  following  which  a  second  saline 
is  given  to  wash  out  the  drug  and  bring  the  parasites  away. 

Trichlnl-\sis.   Dl-\rrhea  in 

This  affection  is  caused  by  Trichinella  spiralis  and  comes  from 
eating  infected  pork.  Digestion  frees  the  lar\'se  from  the  infected  meat, 
which  pass  into  the  intestine,  where  they  remain  and  within  a  week 
produce  numerous  embn.os.  Living  embr\os  leave  the  bowel  and 
migrate  to  the  muscles  by  different  routes,  and  in  ten  days  or  two 
weeks  thereafter  assume  a  larsal  form,  irritate  the  tissues,  and  in  a 
few  weeks  become  enc\sted,  when  they  may  remain  harmless  for  years 
or  cause  local  irritation. 

Symptoms. — When  gastro-intestinal  disturbances  and  diarrhea  are 
caused  b\"  trichina  the  manifestations  arise  within  three  days  follow- 
ing eating  of  the  infected  meat,  or  during  the  time  the  embr\os  are 
journeying  from  the  bowel  to  the  muscles. 

The  treatment  consists  in  avoiding  infected  meat  and  freeing  the 
intestine  of  the  infecting  agents  by  thorough  catharsis  shortly  follow- 
ing their  consumption.  Castor  oil  or  calomel  in  large  doses,  followed 
by  an  active  saline  in  the  morning,  are  usually  effective  when  reinforced 
by  a  santonin  colonic  irrigation. 


SYMPTOMS  421 

AscARiASis,  Diarrhea  in 

ASCARIS    LUMBRICOIDES    (ROUND    OR    LUMBRICOID    WORMS) 

^  The  parasite  Ascaris  lunibricoicles  (Figs.  86,  87)  is  cylindric  in  form, 
pointed  at  both  extremities,  variable  in  size  and  length,  has  an  outer 
corrugated  exterior,  closely  resembles  the  ordinary  earth-worm,  and 
is  frequently  parasitic  within  the  bowel  of  man, 
particularly  children  between  the  ages  of  three  and 
ten  years.  Ascaris  lumbricoidcs  usually  finds  a 
habitat  in  the  small  intestine,  though  it  has  been 
known  to  wander  into  the  ducts,  stomach,  esopha- 
gus, appendix,  and,  more  frequently,  the  colon, 
where  in  the  author's  and  Wheland's  (Figs.  88,  89) 
cases  the  parasites  accumulated  in  large  numbers, 
became  knotted,  and  caused  intestinal  obstruction. 
Usually  in  this  country  not  more  than  half  a 
dozen  are  harbored  by  the  patient,  but  in  tropical 
countries  hundreds  may  be  present  at  the  same 
time,  and  a  large  number  may  be  voided  daily. 

The  infection  occurs  from  eggs  which   gain  en- 
trance   to    the    body    through  water  or  food,  and 


Dorsal  jaw 


V'lg.  <S6. — P^emale 
adult  Ascaris  lumbri- 
coidcs.    (Original.) 


\fntral 
jaw 


Fig.  87.— Head  of  Ax  :iii>  liimbriroides.     ((Original.) 


follows  the  diss(jlving  of  their  shell-like  covering  b\-  ijie  gastric  iuicc. 
The  worms  attain  maturit\-  in  about  a  month  from  the  time  eggs 
appear  in  the  feces. 

Symptoms. — Occasionally  Ascarides  lumbricoides  give  rise  to  no 
sym])ioms,    but    more    often    they  are    accompanied    by  irritability, 


432 


HELMINTHIC    COLITIS    AND    DYSEXTERV.    DIARRHEA    IN 


restlessness,  irregular  appetite,  disturbed  sleep,  nausea,  vomiting, 
itching  at  the  nose  or  anus,  congestion  of  the  intestinal  mucosa, 
colicky  pains,  indigestion,  constipation  or  diarrhea,  and  occasionally 
convulsions  in  the  \er\"  \oung.      In  exceptional  instances  they  migrate 


Fig.  8S. — Complete  obstruction  of  the  small  intestine  and  perforation  caused  by  Ascaris 
lumbricoides.     Appearance  of  bowel  before  it  was  opened. 

to  the  li\er  and  ducts  or  perforate  the  intestinal  wall  (Fig.  88), 
and  give  rise  to  peritonitis  or  collect  in  masses  and  cause  obstruc- 
tion and  other  grave  manifestations. 


Fig.  Sq. — Collection    oi    A>raris    lami)ru oides   which  caused  comi)lele  obstruclion  and 
perforation  of  the  small  intestine.     Appearance  of  gut  after  being  opened. 

Diagnosis. — In  the  i:)resence  of  the  abo\e  s\mptoms  ascariasis 
ought  to  be  suspected,  and  the  stools  should  be  repeatedly  examined 
macroscopically  for  adult  worms  and  microscopically  for  their  ova. 
When  located  in  the  lower  sigmoid  or  rectum  Ascaris  lumbricoides 
can  be  detected  through  the  sigmoidoscope. 


SYMPTOMS  433 

Treatment  of  Ascariasis. — The  dejecta  of  persons  harboring  these 
parasites  should  be  destroyed,  and  patients  so  afflicted  should  be  kept 
clean  (particularly  their  hands)  to  prevent  extension  of  the  infection 
to  others. 

Santonin,  in  doses  ranging  from  gr.  i  to  4  (0.06-0.24)  alone,  or 
in  conjunction  with  medium-sized  doses  of  castor  oil  or  calomel,  ad- 
ministered for  three  successive  evenings,  followed  by  a  purgative,  is 
the  best-known  agent  for  expelling  the  worms,  particularh-  when  the 
patient's  intestine  has  been  emptied  before  the  treatment  is  begun. 
The  amount  of  santonin  administered  to  children  should  be  about 
one-sixth  that  given  an  adult,  and  the  treatment  can  be  repeated  after 
a  few  weeks  ha\'e  elapsed.  Cohnheim  recommends  tlie  following 
formulae: 

R     Santonini  I  _  _  .     .      ,  x 

Calomel     I  aa  gr.  ss  to  iss  (0.03-0.10); 

Saccharianin q.  s. — ]M. 

Ft.  pulv.     Dos.  vi. 
Sig. — A  powder  night  and  morning. 

R     Olei  chenopodii        "I  --     ^,,        /^    \ 

^     -'     -        ^         -ijg  [ aa  gtt.  xc  (6.0); 


Mucilaginis  acac 

Aqua;  dislillata?  1 

S\^rupi  auranlii  corticis  ( 

Ft.  emulsio. 

Sig. — One-half  teaspoonful  three  times  daily. 


aa  gtt.  xc  (6.0). — M. 


When  the  worms  are  almost  lifeless  or  cling  closely  to  the  bowel, 
their  expulsion  can  be  hastened  by  freqtient  copious  high  saline 
enemata. 

AsCARis  CAXis  and  A.  mystax,  so  common  in  dogs  and  cats,  have 
been  encountered  in  the  intestine  of  man,  but  so  seldom  that  their 
further  consideration  is  unnecessary. 

Oxyuriasis.  Diarrhea  in 
oxyuris  vermicularis    pin    or  thread-worms) 

The  parasite  of  oxyuriasis  is  so  small,  t'o  to  f  inch  (3-5  mm.),  that 
it  is  freciuently  overlooked,  except  when  the  examination  is  conducted 
with  a  magnifying  glass.  Pinworm  infection  is  fairly  common  through- 
out the  world,  but  children  suffer  from  it  more  frequently  than  adults. 
Their  habitat  is  the  small  intestine  and  cecum,  where,  after  impreg- 
nating the  opposite  sex,  male  worms  usually  die,  but,  as  Siler  says, 
the  latter  sometimes  reach  the  cecum  and  appendix  in  large  numbers. 
Female  worms  (Fig.  90)  migrate  to  the  cecum,  colon,  and  particularh- 
the  rectum,  from  whence  they  are  ejected  with  the  feces  or  worm  their 
way  through  the  anus,  after  which  they  pass  to  the  perianal  skin, 
gluteal  folds,  vagina,  or  elsewhere,  depositing  their  eggs  and  causing 
itching  and  irritation. 

Symptoms.  The  chief  manifestations  of  the  Oxyuris  vermicularis 
is  intense  [jerianal  itching  (pruritus),  nervousness,  and,  when  they  are 
28 


434 


HELMINTHIC    COLITIS    AND    DYSENTERY,    DIARRHEA    IN 


,  Double-bulbed 
esophagus 


Intestine 


particularly  numerous,  dysenteric  stools,  restlessness,  insomnia,  itching 

of  the  nose,  and  in  children  chorea  or  convulsions. 

Diagnosis. — Frequently  the  author  has  discovered   these  worms 

both  by  macroscopic  examination  and  with  a  hand  magnifying  glass. 

There  are  times  when  they  are  not  present 
in  the  anal  folds,  and  one  must  rely  upon 
finding  their  ova  (Fig.  91)  in  the  stools 
with  the  aid  of  the  microscope,  and  if 
necessary  scrapings  from  the  mucosa  and 
perianal  skin  should  be  examined. 

Treatment. — Care  must  be  taken  to 
prevent  reinfection,  otherwise  parasites  or 
their  ova  will  find  their  way  into  the  body 
again  (by  way  of  the  mouth  or  anus)  in 
patients  who  bite  their  finger-nails  or 
scratch  the  buttocks. 

In  some  instances  repeated  purgation 
ser\-es  to  clear  the  intestine  of  thread- 
worms and  their  ova,  but  usually  santonin, 
gr.  j  to  iv  (0.06-0.24).  or  some  other  re- 
liable anthelmintic,  in  conjunction  with 
frequent  copious  saline,  5j  to  Oj  (4.0- 
500.0).  acid — vinegar,  5iss  to  Oj  (6.0- 
500.0),  or  astringent — quassia,  oj  to  Oj 
(30.0-500.0),  turpentine,  5j  to  Oj  (4.0- 
500.0),   benzin,    njjv    to    x    (0.30-0.60),    or 


Uterus 


Anus  ■ 


Fig.    90. — Ox}-uris   vermicula- 
ris,  female.     (Original.) 


Fig.  91. — Egg  of  OxA,-uris  vermicularis.  (Original.) 


ichthyol  (5  per  cent.)  irrigations  are  necessary  to  effect  a  permanent 
cure  and  relieve  proctitis.  Satisfactory-  and  quick  results  have  been 
obtained  in  several  of  the  author's  cases  by  through-and-through 
medicated  or  saline  irrigations  following  appendicostomy  and  cecostomy. 
Direct  bowel  treatment  following  the  establishment  of  a  cecal  or 
appendiceal  vent  is  particularly  valuable  when,  in  addition  to  worms, 
the  patient  suffers  from  entamebic  or  bacillary  colitis. 


TRICHURIASIS,    TRICIIOCHPHALIASIS 


435 


Trichuriasis,  Trichocephaliasis.  Diarrhea  in 

trichuris  trichiura  cwhip-worm,  trichocephalus  dispar.  tricho- 
cephalus  trichiurus,  trichocephalus  hominis).  ascaris 
trichiurae 

This  lu'lniinth,  owinti  to  its  resemblance  to  a  black  snake  or  whip, 
is  commonly  designated  whip-worm.       Its  distribution  is  worldwide, 


Esophagus 


Esophagus 


OvidutL 

Anus  '^K Mouth 

Fig.  92. — Trichuris  trichiura,  female.     (Original.) 


but  infection  from  this  species  of  worm  is  very  common  in  the  tropics, 
and  in  some  countries  more  than  half  the  population  harbor  them. 


436  HELMINTHIC    COLITIS    AND    DYSENTERY,    DIARRHEA    IN 

The  Trichurus  trichiurus  (Fi-  92)  is  harbored  chiefly  in  the 
cecum,  but  exceptionally  it  is  encountered  in  other  parts  of  the  colon 
and  rectum,  and  causes  little  trouble  other  than  slight  intestinal  dis- 
turbances, except  when  numerous,  and  they  cause  anemia,  penetrate 
the  intestinal  wall,  or  transfix  mucous  folds  and  provide  a  way  for  in- 
fection by  the  intestinal  organisms. 

Symptoms. — Mild  induce  slight  or  no  manifestations,  while  heavy 
infections  are  characterized  by  digestive  disturbances,  the  dysenteric 
sym ptom-com piex ,  abdominal  pain  and  frequent  evacuations  containing 
blood  and  mucus;  restlessness,  headache,  and  anemia. 

The  diagnosis  is  made  by  finding  the  ova  or  whip-worms  in  the 
dejecta. 

Treatment. — Whip-worms  are  more  difficult  to  eliminate  than  other 
helminths,  and  no  specific  agent  has  been  discovered  for  them,  though 
thymol,  gr.  xv.  (i.o),  administered  three  times  daily,  gives  the  best 
results. 

Strongyloidosis,  Diarrhea  in 

strongyloides  intestinalis  strongyloides  stercoralis,  anguil- 
lula  stercoralis,  rhabditis  intestinalis,  septodera  in- 
testinalis) 

The  nematode  of  strongyloidosis  closely  resembles  a  diminutive 
snake  and  differs  from  other  microscopic  worms  in  the  manner  of  its 
sudden  flash  across  the  microscopic  field ;  it  abounds  in  Cochin-China 
and  Italy,  has  been  encountered  less  often  in  different  sections  of 
America,  Asia,  and  the  Philippines,  is  more  prevalent  in  tropical  cli- 
mates, and  is  frequently  associated  with  anemia. 

Worms  of  this  class  find  a  habitat  in  the  upper  small  intestine  and 
show  a  tendency  to  penetrate  the  mucosa  and  glands  of  Lieberkiihn, 
where  they  derive  nourishment  and  deposit  eggs  which  develop  in  the 
gut  wall. 

Symptoms. — Strongyloides  intestinalis  may  bepresent  and  cause  very 
little  discomfort,  but  usually  are  manifest  in  great  numbers  and  cause 
irritative  diarrhea  (dysentery),  evidence  of  which  is  found  in  the  fact 
that  they  are  abundantly  present  in  Cochin-China  diarrhea,  and  the 
number  of  embryos  found  in  this  type  of  infection  is  enormously 
augmented  when  the  evacuations  are  very  frequent. 

The  diagnosis  of  Strongyloides  intestinalis  is  determined  by  detect- 
ing their  ova  or  larva  in  the  evacuations;  the  former  are  rarely  dis- 
coverable except  following  active  purgation,  and  the  latter  must  be 
carefully  protected  in  water,  otherwise  they  will  die  loefore  fully  de- 
veloped. 

Treatment. — Measures  which  will  prevent  infection  taking  place 
by  way  of  the  mouth  or  through  the  skin  are  indicated,  and  thymol, 
gr.  XV  (1.0),  should  be  administered  as  often  as  required  to  cause 
expulsion  of  the  worms  and  their  products. 

CEsoPHAGOSTOMA  Brumpti — This  worm  was  discovered  by  Brumpt 
(1902)   in  cyst-like  deposits  located  in  the  cecum  and  colon  of  an 


ETIOLOGY 


437 


African  negro.  It  ma\-  be  found  free  in  the  bowel  or  as  encysted  larvae 
beneath  the  mucosa;  enlargements  which  vary  from  pinhead  to  hazel- 
nut size  and  contain  a  coiled-up  parasite.  Little  is  known  of  their 
symptomatology  and  pathology  further  than  that  they  penetrate  the 
gut,  are  blood-suckers,  and  cause  anemia  and  irritation,  ner\^ousness, 
and  diarrhea. 

Triciiostroxgvlus. — Three  types  of  this  parasite — Trichostrongy- 
liis  instabilis,  T.  proboluris,  and  T.  vitrinus — are  commonly  found  in  the 
duodenum  of  animals,  sometimes  accidentally  find  their  way  into  the 
intestine  of  man  (Egyptian  peasants),  but  have  no  pathologic  signifi- 
cance. 

The  Triodoxtophorus  diminutus  has  been  encountered  twice  in 
the  large  intestine  of  man,  and  the  symptoms  produced  by  it  were  sim- 
ilar to  those  of  hookworm,  and  l)ecause  of  this  Siler  recommends  thymol 
in  their  treatment. 

Physaloptera  (caucasica  and  mordens)  ha\e  been  discovered  in  the 
intestine  of  man,  but  in  so  far  as  known  do  not  cause  diarrhea. 

Strongylus  gibsoni  is  a  rare  species  of  intestinal  parasites  which  was 
encountered  in  the  dejecta  of  a  Chinaman.  Its  symptomatology  is 
unknown. 

TREMATODES   (FLUKE-WORMS) 

Schistosomiasis,  Diarrhea  in 

Etiology. — This  affection  is  fairly  common  in  trcjpical  and  semitrop- 
ical  countries.  From  1904-09  inclusive  Bray  ton  discovered  104  cases 
among  laborers  w^orking  upon  the  Panama  Canal,  but  intestinal  schisto- 
somiasis is  comparatively  rare,  and  when  it  results  from  infection  by 
the  Schistosoma  japonica,  S.  mansoni,  or  S.  hcematobiiim  the  mani- 
festations closely  similate  those  of  entamebic  and  bacillary  colitis 
(dysentery),  for  which  it  is  often  mistaken. 

There  are  many  different  kinds  of  fluke-worms  parasitic  in  man,  but 
only  a  few  have  been  associated  with  diarrhea,  and  some  of  these, 
though  not  harbored  in  the  bowel,  reflexly  or  otherwise,  induce  diar- 
rhea and  other  intestinal  disturbances.     Among  these  are: 

I  Schistosoma  japonica, 
(i)  Schistosomidm  (blood-flukes). .  .  .  -^  S.  mansoni, 

i  S.  haematobium  (Bilharzia  haematobia). 

(2)  Cladorchis  watsoni  {Paramphistomus  walsoni). 

(3)  Fasciolata  ilocana. 

(4)  Fasciolopsis  buskii  (Disloma  huskii). 

(5)  Ilelerophyes  {Distoma  lieterophyes). 

(6)  GastrodiscHS  Jwminis  {Amphistoma  liominis). 

(7)  Fasciolopsis  fulleborni. 

Schistosoma  Japonica. — In  1904  Katsurada  discovered  the  fluke. 
Since  then  it  has  been  repeatedly  encountered  in  China,  South  Africa, 
the  Philippine  Islands,  and  Central  Japan.  This  type  of  schistoso- 
miasis is  endemic,  and  the  trematode  causing  it  closely  resembles 
Schistosoma  hcematobium,  but  differs  in  that  it  is  smaller,  and  the  skin 


438  HELMINTHIC    COLITIS    AND    DYSENTERY,    DIARRHEA    IN 

of  the  male  parasite  is  smooth  and  dexoid  of  spines  and  the  ventral 
sucker  is  larger  than  the  oral. 

Pathology. — Schistosoma  japan ica  infection  is  characterized  by  en- 
largement of  the  liver  and  spleen,  anemia,  cachexia,  diarrhea,  and 
exhaustion.  Ova  have  been  encountered  in  the  stools,  portal  vein, 
liver,  mesenteric  glands,  mesocolon,  and  intestinal  wall. 

It  is  thought  that  the  habitat  of  the  Schistosoma  japonica  is  in 
the  arteries  and  that  of  the  S.  hcEmatobium  in  the  venous  system. 
In  Katto's  case  ova  were  widely  distributed,  being  found  throughout 
the  submucosa  from  the  cecum  to  the  anus,  liver,  gall-bladder,  pan- 
creas, mesenteric  glands,  and  tunics  of  the  mesenteric  vessels. 

In  addition  to  the  above  changes  in  this  case  there  were  evi- 
dences of  recurring  peritonitis,  enlarged  appendices  epiploica?  and 
mesenteric  glands;  obliteration  of  the  rectovesical  pouch  and  marked 
thickening  of  the  colon  throughout  the  mucous  membrane,  which  was 
congested,  inflamed,  friable,  marked  by  erosions,  and  necrotic;  the 
bowel  wall  was  cartilaginous-like  and  the  rectum  was  enormously 
enlarged,  hardened,  and  f  inch  (1.87  cm.)  thick  at  the  point  where  it 
adhered  to  the  bladder.  The  sigmoid  was  similarly  affected  and 
became  thinner  from  below  upward.  The  posterior  bladder  wall  was 
thickened,  but  the  organ  was  otherwise  healthy.  When  sectioned 
the  rectum  resembled  cartilaginous  tissue. 

In  Katayama's  case,  in  addition  to  the  above,  the  brain  and  its 
covering  were  involved  and  contained  ova.  It  has  been  pointed 
out  that  Schistosoma  japonica  does  not  involve  the  bladder,  and  in 
making  a  diagnosis  this  type  of  infection  must  be  differentiated  from 
Ankylostoma  duodenale. 

Schistosoma  Mansoni. — In  1903  Manson  treated  a  West  Indian, 
in  whom  he  detected  lateral  spined  ova,  who  never  suffered  from 
hematuria,  and  suggested  the  possibility  of  there  being  a  new  species 
of  schistosoma;  later  Sambon  discovered  a  fluke  which  differed  from 
others  in  its  distribution,  pathology,  appearance  of  its  ova,  and  which 
had  lateral  spines,  and  named  it  Schistosoma  mansoni. 

The  authorities  have  not  as  yet  accepted  this  new  species,  which 
resembles  Schistosoma  hcematobium,  and  will  not,  according  to  Siler, 
until  it  has  been  demonstrated  that  the  adult  flukes  are  anatomically 
dissimilar. 

Manson  says  Schistosoma  mansoni  inhabits  chiefly  the  mesenteric 
veins,  and  its  ova  are  deposited  in  the  submucous  layer  of  the  rectum 
and  give  rise  to  dysenteric  symptoms — diarrhea,  tenesmus,  and  mucus, 
blood,  and  ova  in  the  stools.  Sometimes  in  such  cases  small,  large, 
branching  soft  growths  are  to  be  felt  inside  the  sphincter  ani.  They 
resemble  adenomata,  have  been  mistaken  for  piles,  and  may  extend 
up  the  bowel  as  high  as  the  sigmoid  flexure.  On  tearing  up  these 
growths  ova  can  be  seen  in  the  debris. 

The  eggs  of  Schistosoma  mansoni  heive  also  been  found  in  the 
liver,  giving  rise  to  a  peculiar  form  of  hepatic  cirrhosis. 

Schistosoma  Hcematobium  {Bilharzia  Ha^matobia,  Distoma    Hcema- 


PATHOLOGY 


439 


tohium). — This  fluke  (Figs.  93,  94),  so  frequently  responsible  for  hema- 
turia in  the  natives  of  Africa,  Algeria,  Syria,  Persia,  and  particularly 
Egypt,  where  half  the  population  suffer  from  the  infection,  was  dis- 
covered l)y  Bilharz  in  1H51.  Siler  refiorts  having  seen  2  cases  in  New 
York  Cit>',  and  in  holh  instances  the  disease  was  contracted  in  Scnith 
Africa. 


•Oral  sucker 


'    (''^-^r— Esophagus 


■  \cntral  sucker 


Fig.  Q3.  —  Schistosoma 
haematobium,  male.  (Orig- 
inal.) 


Fig.  94.  —  Schistosoma   htemalobium,  female. 
(Original.) 


These  fluke-worms  sometimes  find  their  way  into  the  intestinal 
canal  and  thence  pass  onward  to  the  portal  vein,  or  they  may  gain 
entrance  in  other  ways  and  migrate  to  the  mesenteric,  hemorrhoidal, 
vena  cava,  and  other  veins,  where  they  are  found  in  small  or  large 
numbers. 


440 


HELMINTHIC    COLITIS    AND    DYSENTERY,    DIARRHEA    IN 


Manson  relates  that  Loos  has  seen  the  submucous  tissue  of  the 
bladder  so  full  of  worms  that  a  pair  could  be  found  in  every  area  of 
5  inch  (0.5  cm.)  square. 

Sjrmptoms. — The  manifestations  of  schistosomiasis  vary  accord- 
ing to  the  degree  of  infection,  and  whether  or  not  the  flukes  are  centered 
about  the  bladder  {urinary  schistosomiasis)  or  the  bowel  {intestinal 
schistosomiasis. 

In  urinary  schistosomiasis  {endemic  hematuria,  bilharziasis)  hema- 
turia is  an  early  manifestation,  and  frequent  micturition,  straining, 
backache,  perineal  pain,  and  cystitis  soon  supervene;  later,  when  ova 
enter  the  vesical  tunics,  they  become  ulcerated  or  dotted  over  with 
papillomata.  Finally,  the  ureters  and  kidneys  may  become  in- 
volved or  abscesses  form  which  result  in  urinary  fistula?.  When  the 
rectovesical  region  is  invaded  and  flukes  enter  the  rectal  veins  the 
patient  invariably  suffers  from  an  aggravated  type  of  diarrhea,  and 
where  the  vagina  is  involved  the  mucosa  becomes  thickened  and 
cauliflower-like  excrescences  form,  which  when  sectioned  reveal  both 
ova  and  adult  parasites.  These  flukes  have  also  been  frequently  en- 
countered in  the  lungs  and  kidneys,  and  their 
ova  in  various  parts  of  the  body. 

Intestin.al  schistosomiasis  is  character- 
ized by  the  so-called  dysenteric  group  of 
symptoms — abdominal  pain,  water^^  evacua- 
tions containing  mucus,  pus,  and  blood,  and 
tenesmus.  When  adult  worms  enter  the  veins 
of  the  walls  in  the  large  intestine  and,  more 
particularly,  the  rectum  the  gut  becomes 
greatly  thickened,  indurated,  and  gives  a 
gritty  sensation  when  incised.  Ulceration 
of  the  rectal  mucosa  is  verv'  common,  and 
when  the  infection  results  from  Schistosoma 
manson i  frequently  papillomata  can  be  seen 
projecting  into  the  gut  lumen. 

These  polypoid-like  growths  may  extend 

high  in  the  bowel  or  be  large,  located  just 

above  the  sphincter  ani,  and  be  mistaken  for 

hemorrhoids.      By  incising  and  cureting  such 

neoplasms  adult  fluke-worms  and  their  ova 

can  be  exposed  for  examination. 

Thickening  of  the  liver,  spleen,  and  peritoneum  is  common,  and 

in  some  instances  the  sacrococcygeal  region  becomes  infiltrated  with 

ova  and  subcutaneous  fistulse  form. 

The  diagnosis  of  schistosomiasis  is  usually  easy  when  a  routine 
examination  is  made  of  the  dejecta  of  patients  who  suffer  from  the 
dysenteric  group  of  symptoms,  particularly  when  the  sufferer  comes 
from  a  countn.-  where  schistosomiasis  is  endemic. 

Macroscopic  and  microscopic  examinations  of  the  stools  for  eggs 
(Fig.  95)  enable  the  examiner  to  exclude  bacillary  and  entamebic  dysen- 


Fig.  95.  —  Developmental 
form  of  Schistosoma  haema- 
tobium egg  showing  mirocid- 
ium.     (Original.) 


TREATMENT  44I 

tery,  and  dcnionstralc  that  the  inlectifjn  is  (kic  to  schistosoniida' ,  and 
determine  which  of  the  species  is  responsible  for  the  trouble.  When 
the  colon  and  sigmoid  flexure  are  involved,  owing  to  its  thickened  and 
indurated  condition  the  gut  can  be  plainly  outlined  by  palpation, 
and  when  the  disease  (as  it  usually  does  in  Schistosoma  mansoni 
infection)  attacks  the  rectum,  the  thickened  ulcerated  mucosa,  hard- 
ened bowel  wall,  and  papillomatous  growths  can  be  noted  by  digi- 
tal examination,  and  these  and  other  lesions  of  the  sigmoid  and  rec- 
tum can  be  accurately  inspected  through  the  sigmoidoscope. 

Urinary  schistosomiasis  (Schist(jsoma  haMnatobium  infection) 
should  be  suspected  in  Egyptian  and  South  African  patients  who  suffer 
from  hematuria  and  dysentery,  and  the  urine  and  blood  should  be  ex- 
amined for  special  flukes  and  their  ova,  which  can  be  differentiated 
from  the  eggs  of  the  other  types  owing  to  the  arrangement  of  their 
spines. 

Prognosis. — When  schistosomiasis  is  discovered  early  and  the 
patient  is  prevented  from  becoming  reinfected  the  prognosis  is  good, 
but  in  neglected  cases,  where  flukes  and  their  ova  have  been  permitted 
to  accumulate  in  large  numbers  and  enter  the  circulation  and  tissues 
in  widely  separated  parts  of  the  body,  the  suijject's  condition  becomes 
deplorable  or  death  ensues. 

Under  favorable  conditions  the  symptoms  induced  by  the  ova  or 
adult  fluke-worms  may  persist  months  or  years  after  the  patient  has 
been  removed  to  a  non-infected  district. 

Treatment. — Schistosomiasis  is  often  caused  by  contaminated 
water,  and  because  of  this  in  suspected  regions  the  water  should  be 
boiled  or  filtered,  and  precautions  should  be  taken  to  prevent  toilets 
and  barns  from  draining  into  the  water-supply. 

No  specific  has  been  discovered  which  will  destroy  schistosomidce 
without  poisoning  the  patient  or  injuring  the  rectal  or  vesical  mucosa. 
By  taking  a  slow  counse  much  can  be  done  to  add  to  the  patient's 
comfort,  heal  lesions  in  the  mucosa,  minimize  or  get  rid  of  the  adult 
worms  and  their  ova  by  irrigating  the  bladder  and  intestine  with 
mild  antiseptic  irrigations,  keeping  the  patient  quiet,  having  him 
abstain  from  indiscretions,  restricting  his  diet  to  bland  nutritious 
foods,  and  giving  him  urotropin,  gr.  v  (0.30),  three  times  daily,  when 
hematuria  is  a  complication. 

Methylene-blue  in  3-gr.  (0.18)  doses  or  fluidextract  of  male  fern, 
iTjv  (0.30),  three  times  daily,  have  proved  useful  in  these  cases. 

.  Stones  may  be  crushed  or  washed  out  by  suprapubic  or,  prefer- 
ably, perineal  cystotomy  and  drainage. 

In  intestinal  schistosomiasis  where  infection  is  mild  a  great  deal  can 
be  done  to  relieve  the  patient  and  minimize  or  get  rid  of  the  parasites 
by  ichthyol,  balsam  of  Peru,  permanganate  of  potassium,  2  per  cent., 
or  weak  silver  irrigations  introduced  through  the  anus  or  an  appendi- 
ceal or  cecal  opening.  The  inflamed  and  ulcerated  rectal  mucosa  of 
the  lower  bowel  can  be  benefited  or  healed  by  fairly  strong  topical 
applications  or  electric  cauterization,  and  pajiillomata  within  can  be 


442  HELMINTHIC    COLITIS    AND    DYSENTERY,    DIARRHEA    IN 

snared  or  clamped  off  with  a  Gant  valve-clamp.  When  the  rectum 
and  sigmoid  are  extensively  involved  and  the  mucosa  is  covered  by 
numerous  excrescences  an  artificial  anus  or  extirpation  is  indicated, 
and  in  cases  where  the  colon  is  similarly  incapacitated  it  should  be 
removed  or  excluded  by  dividing  the  ileum  and  uniting  it  below  the 
seat  of  infection  to  the  sigmoid  flexure  or  rectum. 

Where  adult  worms  or  their  ova  find  their  way  into  the  subcu- 
taneous structures  in  the  coccygeal  and  sacral  regions  or  elsewhere 
about  the  rectum,  accumulate,  and  form  abscesses  and.fistulae,  the 
latter  should  be  incised,  cureted,  and  drained. 

Cladorchis  Watsoni. — This  fluke  was  discovered  by  Watson  in  a 
German  West  African  negro,  who  succumbed  to  starvation  and 
obstinate  diarrhea,  wherein  the  evacuations  were  frequent,  fluid,  bile 
stained,  and  contained  many  yellowish,  translucent,  and  ovoid-shaped 
parasites.  Autopsy  revealed  a  jejunum  filled  with  live  and  dead  trem- 
atodes  (flukes),  some  of  which  were  attached  to  the  congested  mucous 
membrane,  but  the  parasites  had  not  aftected  other  segments  of  the 
bowel  or  other  organs. 

Fasciolata  Ilocana. — This  parasite  was  discovered  by  Garrison 
in  1907,  who  examined  the  dejecta  of  5000  natives  living  in  the  prov- 
inces of  the  island  of  Luzon,  and  found  it  in  5  instances.  In  these 
and  other  cases  the  eggs  of  this  fluke  were  observed  in  the  stools,  and 
in  one  instance,  with  the  aid  of  male  fern,  twenty-one  parasites  were 
expelled. 

The  manifestations  incident  to  the  parasites  were  unimportant. 

Fasciolopsis  Buskii. — This  parasite  has  been  encountered  more 
frequently  than  the  abo\e,  and  shows  a  prevalence  for  India,  Borneo, 
Southern  China,  and  Sumatra;  its  habitat  is  the  small  botcel,  and  it 
induces  diarrhea,  probably  through  the  local  irritation  which  it  induces. 

Heterophyes. — This,  the  Egyptian  intestinal  fluke,  was  discovered 
by  Bilharz  (1851),  at  Cairo,  in  the  bowel  of  a  child.  More  recently 
it  has  been  encountered  fairly  often  in  Egypt  and  occasionally  in 
Japan.  This  fluke  is  probably  more  common  than  is  believed,  but 
is  rarely  detected  because  the  intestinal  disturbances  induced  by  it  are 
slight,  the  nature  of  the  infection  is  not  suspected,  and  because  de- 
jecta are  not  examined. 

Gastrodiscus  Hominis. — This  fluke  has  been  encountered  less 
than  half  a  dozen  times,  and  then  in  India,  except  in  the  case  of  a 
Filipino,  and  little  or  nothing  is  known  of  the  manifestations  incited 
by  it.  Lewis  and  MacConnell  (1876)  at  autopsy  discovered  it  near 
the  ileocecal  valve,  and  Simpson  (1857)  found  the  parasite  in  the  cecum 
and  ascending  colon  of  an  Indian  who  died  from  cholera.  It  has 
suckers,  enabling  it  to  cling  to  the  mucosa,  which  at  the  points  of 
lodgment  is  congested  and  swollen.  When  parasites  are  present  in 
large  numbers  they  induce  considerable  irritation  and  diarrheal 
manifestations. 

Fasciolopsis  Fullehorni. — This  parasite  has  been  encountered  once 
by  Rodenwalt  (1909)  in  a  patient  who  suft'ered  from  a  typhoid-like 


TREATMENT  443 

fever,  and  the  diagnosis  of  these  trematodes  consists  in  finding  either 
their  eggs  or  adult  flukes  in  the  dejecta  during  Hfe,  or  in  the  feces  or 
bowel  at  autopsy. 

When  repeated  15-gr.  (i.o)  doses  of  thymol  proves  ineffective,  the 
treatment  recommended  for  tapeworms  usually  brings  relief. 

From  what  has  been  said  concerning  helminthiasis  the  importance 
of  a  routine  macroscopic  and  microscopic  examination  of  the  dejecta 
of  persons  afflicted  with  diarrhea  is  obvious,  for  in  this  way  only  can 
one  determine  if  there  is  a  helminthic  infection,  and  if  so,  whether 
or  not  it  is  complicated  by  an  entamebic,  bacillary,  or  protozoal  colitis 
which  would  aggravate  the  patient's  condition. 


CHAPTER   XXXVIII 

PROTOZOAL     (PARASITIC)     COLITIS    (PROTOZOAL    DYSEN- 
TERY),   DIARRHEA   IN 

BALANTIDIC,   FLAGELLATE.  CILUTE,  COCCIDIC 

Animal  protozoa  in  one  form  or  another  have  been  frequently 
found  associated  with  ordinary  diarrhea  (colitis)  and  the  dysenteric 
symptom-complex,  frequent  stools  containing  blood  and  mucus,  rec- 
tal tenesmus,  and  abdominal  pain,  and  in  some  instances  two  or  more 
varieties  of  protozoa  have  been  met  with  in  the  same  case. 

Of  the  numerous  types  of  protozoa,  those  most  frequently  observed 
under  the  above  conditions  are:  (i)  ameb(E  and  entamehce  (rhizapodes) ; 
{2)  flagellates  (mastigopJiores);  (3)  ciliates  {infusoria,  Balantidiiim  coU), 
and  (4)  coccidia  (sporozoa). 

AMEBAE    AND    ENTAMEBAE 

The  characteristics  and  causal  relation  of  these  protozoan  organ- 
isms to  colitis  (dysentery)  have  already  been  fully  discussed,  and  a 
further  consideration  of  them  would  be  out  of  place  here. 

FLAGELLATES 

Flagellates  possess  whip-like  processes  (flagella)  which  aid  them 
in  their  locomotion  and  feeding.  Parasitic  flagellates  thrive  in  tropical 
and  semitropical  countries,  where  they  are  widely  distributed.  The 
organisms  of  this  class  which  have  been  most  frequently  discovered 
in  persons  suffering  from  diarrhea  and  dysentery,  and  which  are  be- 
lieved to  be  the  cause  of  or  an  aggravating  factor  in  these  conditions, 
are:  (i)  Cercomonas  hominis;  (2)  Trichomonas  hominis,  and  (3)  Lam- 
blia  intestinalis  (Figs.  96-98).  The  parasites  gain  entrance  to  the  body 
through  the  drinking  of  polluted  water  or  eating  food  contaminated  by 
infected  mice  or  rats.  The  pathogenicity  of  flagellates  has  been  estab- 
lished, and  the  degree  of  bowel  disturbance  consequent  upon  them  is 
directly  proportionate  to  the  number  of  parasites  present,  which  ex- 
plains why  a  flagellate  colitis  in  one  instance  may  be  very  mild,  and 
in  another  extremely  severe  and  characterized  by  the  dysenteric 
symptom-complex. 

Apparently,  flagellates  find  a  habitat  in  both  the  small  or  large 
intestine,  where,  through  attaching  themselves  to  the  mucous  mem- 
brane, they  incite  peristalsis,  augment  the  secretion  of  mucus,  and 
induce  diarrhea  rather  b}'  irritation  than  ulceration,  as  manifested  in 
bacillary  and  entamebic  colitis  (dysentery). 
444 


FLAGELLATES 


445 


Iiidixiduals  liarboring  flagellates  occasionally  suffer  severely  from 
diarrhea,  and  their  stools  contain  an  aljundance  of  blood,  mucus,  and 
sometimes  pus.  Under  such  circumstances  there  may  be  a  dual  in- 
fection, when  E)itama.'ba  histolytica,  bacilli  of  the  Shiga-Flexner  or 
other  type,  or  Balantidium  coli  are  found  in  conjunction  with  flagel- 
lates, which  would  help  to  account  for  the  seriousness  of  the  infection. 

Simon  has  obser\ed  50  cases  of  amebic  dysentery  wherein  in  a  large 
proportion  of  the  stools  he  found  Cercomonas  hominis  and  Entamoeba 
histolytica. 


Fig.  96. — Lamblia  intestinalis,  front 
and  profile  view.  (After  Grassi  and 
Skeviakov.) 


Fig.  97. — Lamblia  intestinalis  attached 
to  an  epithelial  cell.  (After  Grassi  and 
Skeviakov.) 


It  is  reasonable  to  suppose  that  as  a  result  of  the  trauma  or  erosions 
to  the  mucosa  induced  by  flagellates,  mixed  infection  promptly  ensues, 
participated  in  by  colon  and  paratyphoid  bacilli,  streptococci,  staphy- 
lococci, and  other  intestinal  organisms  which  under  favorable  condi- 
tions manifest  pathogenic  propensities,  to  the  end  that  numerous  lesions 
variable  in  size  are  formed.  Some  investigators  hold  that  flagellates 
are  capable  of  affecting  marked  organic  changes  in  the  bowel,  but 


Fig.  98. — Cysts  of  Lamblia  intestinalis.     (.\flcr  Grassi  and  She\-iakov.) 

Roos  maintains  that,  while  they  undoubtedly  induce  obstinate  intes- 
tinal disturbances  (dysentery,  etc.),  they  do  not  seem  to  possess  inde- 
pendently the  power  of  causing  deep  intestinal  lesions.  Flagellates 
apparently  do  not  penetrate  the  mucosa  and  ha\e  been  observed  in 
the  stools  of  healthy  individuals,  which  would  indicate  that,  like 
entamebae,  they  may  be  harbored  within  the  intestine  without  harm 
until  favorable  conditions  develop  which  would  incite  them  to  activity. 


446  PROTOZOAL    (parasitic)    COLITIS,    DIARRHEA    IN 

Flagellates  may,  with  the  microscope,  be  seen  in  fresh  dejecta 
actively  motile  or  encysted. 

Lamblia  intestinalis  are  not  always  present  in  the  stools,  and  for 
diagnostic  purposes  it  is  necessary  to  remove  them  from  the  intestinal 
epithelium  to  which  they  cling. 

Spirochetes  are  varied  and  difficult  to  classify,  because  in  some 
respects  they  resemble  protozoa  and  in  others  bacteria.  It  is  known 
that  the  Spirochceta  pallida  is  concerned  in  syphilitic  enterocolitis, 
since  it  has  been  discovered  in  the  dejecta,  discharges  and  scrapings 
taken  from  ulcers,  and  persons  afflicted  with  intestinal  syphilis.  Other 
types  of  spirochetes  (flagellates)  have  been  so  frequently  observed  by 
different  investigators,  in  connection  with  inflammatory  and  ulcera- 
tive bowel  affections,  designated  as  spirillar  dysentery,  spirillar  enteritis, 
diarrhee  a  spirochcetes ,  spirillosis  intestinalis ,  etc.,  that  they  are  now 
looked  upon  as  a  comparatively  frequent  cause  of  intestinal  disturb- 
ances characterized  by  frequent  bloody  stools,  abdominal  discomfort, 
and  rectal  tenesmus. 

Spirochetes  have  been  frequently  observed  in  the  healthy  dejecta 
and  in  the  stools  of  patients  suffering  from  colitis,  and  more  par- 
ticularly in  the  infantile  form,  as  found  in  the  tropics.  "There  can  be 
little  doubt  that  in  various  morbid  conditions  spirochetes  find  the  sur- 
face of  inflamed  mucous  membranes  highly  favorable  to  their  growth, 
and  that  they  multiply  with  extraordinary  rapidity;  but  no  fatal  case 
of  spirillar  diarrhea  has  been  described,  nor  do  any  definite  postmortem 
reports  appear  to  have  been  published.  The  pathology  of  the  condition 
is,  indeed,  very  doubtful,  and  it  is  questionable  whether  any  etiologic 
function  can  be  ascribed  to  the  organisms"  (Brown). 

CILIATES 

Ciliates,  the  most  complex  of  protozoan  parasites,  have  in  recent 
years  assumed  considerable  importance,  because  investigators  who 
have  been  studying  the  relation  of  parasites  to  dysenteric  and  other 
intestinal  affections  have  so  frequently  detected  them  in  the  dejecta 
alone  and  associated  with  Entamoeba  coli  and  histolytica,  Shiga's, 
Flexner's,  and  Strong's  bacilli,  and  other  harmless  and  pathogenic 
micro-organisms. 

Of  the  infusoria,  the  Balantidium  minutenm  (Fig.  99),  Nyctotherus 
faba  (Fig.  100),  N.  giganteum,  N.  africanus  (Fig.  loi),  and  Chilodon 
dentatus  are  the  only  types  which  have  been  observed  in  connection 
with  dysenteric  colitis  in  man.  The  Balantidium  coli  deserves  spe- 
cial consideration  here  because  of  the  frequency  with  which  it  has 
been  encountered,  while  the  other  ciliates  do  not,  and  will  not  be 
discussed  further  because  of  the  infrequency  with  which  they  are  as- 
sociated with  intestinal  disturbances  complicated  by  diarrhea. 

Balantidium  Coli;  Paramoecium  Coli  (Fig.  102). — The  balantidia 
are  the  most  important  of  the  ciliates,  and  these  infusoria,  which  are 
the  largest  of  the  protozoan  parasites,  were  first  described  by  Malm- 
sten  in  1857,  but  the  organisms  and  their  relation  to  intestinal  lesions 


BALAXTIDIUM    COLI ;    PARAMCECIUM    COLI 


447 


and  diarrhea  were  iiol  carefully  studied  and  determined  until  the 
present  decade,  and  there  remains  \et  much  to  be  learned  concerning 
their  distribution  and  manner  in  which  they  gain  entrance  to  and 
infect  the  colon. 


Fig.  99. — Balantidium   minuteum:  M,  Fig.  100. — Xyctotherus  faba:  M,  mac- 

macronudeus;    m,   micronucleus.       (After       ronucleus;     m,     micronucleus;     a,     anus. 
Schaudinn.)  (After  Schaudinn.) 

The  investigations  of  Strong,  Musgrave,  Opie,  Brooks,  Mitter, 
Doflein,  Xoe,  Eberlein,  and  Bundle  have,  in  recent  years,  added 
greatly  to  our  knowledge  concerning  the  Balantidia  coli.  These  in- 
fusoria have  frequently  been  discovered  in  the  intestines  of  swine  and 


|I!^:J.;.^^::W'# 


Fig.    loi. — Nyctotherus  africanus  Castel- 
lani.     (Castellani  and  Chalmers.) 


/ 


\ 


\ 


Fig.  102. — Balantidium  coli,  from  an 
ulcer  of  the  large  intestine  of  man.  Mag- 
nified, 600  :  I.     (Braun  and  Liicke.) 


less  often  in  man,  and  in  the  former  the  habitat  of  these  organisms 
is  in  the  cecum,  but  in  human  beings  they  show  a  prevalence  for  the 
lower  ileum,  cecum,  and  rectum. 

An  epidemic  of  dysentery  which  occurred  among  the  orangoutangs 
of  the  New  York  Zoological   Park  was  ascribed  by  Harlow  Brooks 


448  PROTOZOAL   (parasitic)  colitis,  diarrhea  IX 

to  Balantidium  coli,  and  the  symptoms  and  lesions  were  similar  to 
those  of  balantidic  colitis  in  man.  The  organism  is  less  widely 
distributed  than  entameba^  or  the  Shiga,  Flexner.  Strong,  Kruse,  etc., 
bacilli;  nevertheless,  it  has  been  encountered  in  one  or  more  instances 
in  Sweden,  Finland,  Scandinavia,  Russia,  Germany,  Philippine  Islands, 
China,  Italy,  the  United  States  and  other  sections  of  North  America, 
and  the  author  has  obser\-ed  a  case  from  Xew  Jerse\'. 

The  recorded  cases  of  balantidic  colitis  or  dysentery  show  that 
thus  far  the  disease  has  been  met  with  more  often  in  the  first-named  or 
colder  countries  than  in  warmer  climates,  but  some  of  the  best  inves- 
tigators belie^■e  it  will  eventually  be  classified  among  the  affections 
common  to  the  temperate  zones  and  tropics. 

Balantidic  infection  supposedly  results  from  the  drinking  of 
water,  milk,  or  eating  food  contaminated  by  the  organisms,  and  it  has 
been  demonstrated  that  they  can  survive  in  water  many  hours. 

Balantidia  are  most  frequently  found  in  individuals  who  have 
worked  among  hogs,  made  sausage,  or  eaten  pork,  and  have  never  been 
encountered  among  Jews  or  Mohammedans  in  the  tropics,  and  because 
of  this  some  authorities  hold  that  the  disease  is  frequently,  if  not 
always,  contracted  from  swine.  The  statistics  of  Musgrave's  117 
collected  cases  support  this  view,  because  25  per  cent,  of  the  patients 
gave  a  history  which  pointed  to  infection  from  this  source. 

The  manner  in  which  the  infection  takes  place  has  not  been  defi- 
niteh-  shown,  and  it  is  thought  that  some  active  balantidia  are  destroyed 
by  the  gastric  juice,  and  that  others  are  protected  by  encystment  or 
attenuated  by  the  gastric  contents  and  do  not  infect  the  gut  until  they 
reach  their  favorite  places  of  habitat — viz.,  the  lower  ileum,  cecum,  or 
rectum. 

Bowman  has  carefully  investigated  human  balantidia  relative  to 
this  point,  but  was  unable  to  find  evidences  of  encystment;  neverthe- 
less he  believes  that  if  man  is  infected  through  pork,  it  probably  re- 
sults from  the  resistant  encysted  forms. 

Cultivation  of  the  organisms  has  not  proved  satisfactory,  though 
balantidia  have  been  known  to  li\e  from  one  to  six  days  on  suitable 
media.  A  number  of  attempts  have  been  made  to  infect  animals  with 
balantidia,  but  nothing  has  come  of  the  experiments.  Bowman 
persistently  tried  and  failed,  though  he  injected  infected  feces  into  the 
rectum  of  a  monkey,  introduced  them  into  the  large  bowel  through  a 
colostomy  opening,  and  sutured  a  section  of  an  ulcer  removed  from  a 
patient  suffering  from  balantidic  colitis  to  the  animal's  colon,  but  the 
results  were  negative  in  each  instance. 

Balantidia  have  been  repeatedly  found  in  the  feces  from  the 
intestine  of  healthy  individuals,  persons  who  suffered  slightly  from 
diarrhea,  and  patients  afifficted  with  severe  ulcerative  colitis,  where 
the\-  e\idently  were  inciting  factors.  From  this  it  appears  that 
under  \arying  conditions  these  organisms  may  be  harmless,  induce 
mild  intestinal  disturbances,  or  cause  malignant  dysenter\'  (colitis),  but 
most  often  they  have  been  associated  with  proctosigmoiditis. 


BALANTIDIUM    COLI ;    PARAMECIUM    COLI 


449 


Altogether  about  125  cases  of  so-called  l)alanli(lic  dysentery 
(colitis)  have  been  recorded,  and  of  these  instances  the  Balantidium 
coli  was  evidently  the  chief  etiologic  factor,  because  it  was  rarely 
encountered  in  the  presence  of  other  pareisites,  helminths,  or  the  Shiga, 
Flexner,  Kruse,  or  other  dysenteric  bacilli,  and  almost  never  in  con- 
junction with  the  Entamoeba  histolytica.  The  author  has  treated  a 
few  patients  whose  feces  contained  entameba-  and  balantidia  and 
Hanes  has  treated  several. 

In  Musgrave's  collected  cases  (117)  there  were  2  children  and  1 15 
adults,  and  except  in  2  instances  the  patients  suffered  from  diarrhea 
or  the  dysenteric  symptom-complex. 


Fig.  103. — Reproduction  of  Balantidium  coli:  i,  2,  3,  4,  5,  Asexual  reproduction  by 
sextuple  generation;  6.  resistant  cj^st  with  a  single  individual;  7,  copulation  of  two  infu- 
soria; 8,  reproduction-cyst;  9,  cyst  contents. 


The  Balantidium  coli  has  an  egg-shaped  body  and  measures  from 
0.07  to  0.1  mm.  in  length  by  0.05  to  0.07  mm.  in  width,  dimensions 
which  make  it  possible  for  the  organism  to  be  seen  with  the  naked  eye 
in  mucus  collected  from  the  rectum.  It  is  enveloped  by  transparent 
protoplasm  studded  with  cilia,  which  are  factors  in  its  forAvard  and 
rotary  motions,  and  which  at  the  peristome  assume  greater  length, 
where  they  aid  in  corralling  food  elements.  The  organism  is  rounded 
at  the  anterior  end  (the  location  of  the  funnel-shaped  slit  or  peri- 
stome), upon  the  ventral  surface  of  which  is  situated  the  culde sac -Wk^c 


450 


PROTOZOAL    (parasitic)    COLITIS,    DIARRHEA    IN 


mouth,  which  some  beUeve  ends  as  a  furrow,  and  in  others  leads  to  a 
gullet,  and  is  round  but  broader  at  the  posterior  extremity,  wherein  is 
located  the  anal  outlet. 

Balantidia  possess  a  large  bean-shaped  macronuclcus  and  a  small 
round  micronucleus  (near  the  anterior  pole),  and  in  the  glandular  pro- 
toplasm which  fills  its  interior  are  regularly  found  two  or  more  con- 
tracting vacuoles  and  occasionally  fat  and  starch  granules  and  red  and 
white  corpuscles. 

Reproduction  of  the  Balantidium  coli  takes  place  by  budding,  simple 
transverse  division,  and  sexual  conjugation  (Fig.  103).  "In  unfavorable 
conditions  of  life,  such  as  it  is  likely  to  meet  when  expelled  from  the 
intestine,  and  possibly  also  as  a  normal  stage  of  sexual  reproduction, 
balantidium  encysts  and  form  minute  sporocytes  of  exceptional  vital- 
ity and  tenacity.  These  are  doubtless  the  medium  by  which  in  ordi- 
nary circumstances  infection  is  conveyed  from  host  to  host"  (Brown). 

In  fluid  dejecta  this  protozoan  parasite  is  markedly  active,  evi- 
dences of  which  are  to  be  seen  with  the  eye  or  microscope  by  its  almost 
incessant  forward  and  rotary  movements,  and  the  form  of  the  organ- 
ism changes  to  meet  conditions  when  during  its  travels  it  meets  with 


1       '  y^-T'    2 

Fig.  104. — Balantidium  giganteum.     (x\fter  Krause.) 

an  obstruction,  as,  for  instance,  a  projection  of  it  may  become  narrow 
and  like  a  pseudopod,  which,  if  sectioned,  would  resemble  the  budding 
reproduction  of  the  organism. 

The  Balantidia  coli,  like  other  ciliata  and  flagellata,  are  usually 
encountered  in  pairs  (Fig.  104)  or  large  numbers,  both  in  prepared 
feces  and  the  stained  section  of  intestinal  ulcers  taken  from  patients 
afflicted  with  balantidic  colitis. 

"The  rapid  circular  motion  of  the  peristome  cilia  seems  to  exert  an 
attraction  which  brings  the  organisms  in  contact.  I  have  observed 
many  times  in  fresh  feces  two  of  them  moving  along  rapidly  in  the  fecal 
material;  suddenly,  on  approaching  each  other,  dart  together  and  re- 
main in  this  position  for  a  considerable  period  of  time,  though  no  inter- 
change of  material  could  be  seen  taking  place  between  them  and  no 
evidence  of  reproductive  change"  (Bowman). 

In  persons  who  harbor  balantidia  the  organisms  may  be  constantly 
or  intermittently  present  in  the  feces,  and  usually  manifestations  of 
the  disease  are  more  marked  in  proportion  to  the  number  present, 
though  cases  are  on  record  where  they  were  abundant  in  the  stools  and 
the  patient  suffered  from  nothing  more  than  a  mild  proctosigmoiditis. 


BALANTIDIUM    COLI  ;    PARAMCECIUM    COLI  45 1 

Histo pathology. — The  changes  ^vhich  take  place  in  the  bowel  inci- 
dent to  balantidic  coHtis  are  variable,  being  slight  in  some  and  exten- 
sive in  other  cases  (see  P'ig.  109),  and  it  appears  that  they  are  influenced 
by  the  patient's  physical  condition  at  the  time  of  infection,  other  com- 
plicating diseases,  and  virulence  of  the  infection,  for,  as  has  already 
been  shown,  beilantidia  have  been  observed  in  the  feces  and  intestine 
of  healthy  indixiduals,  those  who  suffered  from  mild  types  of  diarrhea, 
and  in  patients  afflicted  with  malignant  colitis  (entamebic  and  bacil- 
lary),  as  evidenced  by  frequent  evacuations  containing  an  abundance 
of  mucus,  pus,  blood,  with  tenesmus  and  characteristic  abdominal 
pains. 

Autopsies  ha\e  been  made  in  about  35  cases  of  balantidic  colitis, 
in  some  of  which  there  was  a  catarrhal  congestion  of  the  mucosa,  in 


Fig.    105. — Balantidium    coli   passing   from    mucosa   through   the   muscularis   mucosa. 

(After  Strong.) 

Others  diphtheric  patches,  and  still  others  (which  constituted  the  ma- 
jority) where  an  extensive  ulceration  marked  the  disease  (see  Fig.  109). 

The  disease  is  insidious  and  the  tissue  changes  are  slow  but  con- 
tinuously progressive  long  after  the  infection  has  become  extensive,  and 
the  lesions  in  many  respects  resemble  those  of  entamebic  colitis,  which 
form  very  much  more  rapidly.  Balantidic  ulcers  ha\e  been  known  to 
involve  the  lower  ileum  (exceptionally)  along  with  the  large  intestine, 
but  the  disease  is  most  destructive  in  the  colon  (Fig.  105),  and  more 
particularly  the  cecum  and  rectum,  where  the  lesions  are  numerous  and 
deep  as  a  result  of  necrosis  which  occurs  about  the  infected  areas. 

Balantidia  are  not  solely  responsible  for  the  excavated  ulcers  pres- 
ent, because  here,  as  in  other  bowel  disturbances  accompanied  by 
displacement  of  the  epithelium,  there  is  a  mixed  infection  participated 


452 


PROTOZOAL    (parasitic)    COLITIS,    DIARRHEA    IN 


in  both  by  the  specific  agent  (Balantidium  coli)  and  the  colon  or  para- 
typhoid baciUi,  streptococci,  staphylococci,  or  other  pathogenic  organ- 
isms in  the  gut.  The  ulcers  (Fig.  io6)  of  balantidic  colitis  are,  if 
anything,  more  virulent  than  those  of  entamebic  (histolytica)  infection, 
tend  to  a  more  prolonged  chronicity.  and  do  not  respond  as  readily  to 
treatment. 

In  a  case  obser\-ed  by  the  author  the  bowel  from  the  upper  ex- 
tremity of  the  anal  canal  to  the  highest  visible  point  of  the  sigmoid 
(through  the  sigmoidoscope)  was  involved  in  the  destructive  process; 
the  ulcers  were  too  numerous  to  count,  and  were  situated  in  close 
proximity  to  each  other  or  overlapped  in  some  instances.  The  mu- 
cosa, as  seen  at  the  site  of  recent  lesions,  was  smeared  with  mucus, 


Fig.  1 06. — Balantidium  coH  in  submucosa  and  surrounding  tissue.     (After  Strong.) 


tinged  with  blood,  appeared  darker  than  the  healthy  membrane, 
and  it  was  thought  that  this  was  due  to  necrosis,  since  the  tissue 
overhanging  the  edges  of  formed  ulcers  was  necrotic.  A  number  of 
infected  areas  were  undermined,  and  in  some  instances  yellow  pus 
could  be  expressed  through  the  ulcers  when  the  adjacent  mucosa  was 
compressed  with  the  finger,  which  showed  that  pyogenic  bacteria 
had  been  acti\'e  and  diminutive  abscesses  had  formed. 

The  dimensions  of  the  lesions  were  not  always  the  same,  but  typic 
ulcers  varied  from  0.4  to  3  or  5  cm.  in  diameter,  and  differed  from 
tubercular  and  s\philitic  ulcers  in  that  they  exhibited  no  inclination 
to  follow  the  direction  of  the  blood-vessels  or  collect  in  large  numbers 
upon  the  mesenteric  side  of  the  bowel. 

As  a  result  of  undermined  and  indurated  rings  about  the  sores 


BALAXTIDIUM    COLI ;    FARAMCECIUM    COLI  453 

the  unbroken  mucosa  was  thickened  and  presented  an  uneven,  some- 
what lobulated  appearance.  The  lesions  of  balantidic  coHtis  occa- 
sionally penetrate  the  bowel  tunics  down  to  the  serosa  (see  Fig.  109), 
and  have,  at  least  in  one  case,  caused  perforation  of  the  cecum. 

The  author  judged  that  in  ceises  observed  by  him  the  entire  colon 
and  cecum  were  involved  like  the  sigmoid  flexure  and  rectum,  because 
the  bowel  could  be  plainly  outlined  by  palpation  owing  to  its  indurated 
and  thickened  condition.  Diarrhea  was  persistent,  there  was  an 
abundance  of  mucus,  pus,  and  blood  in  the  stools,  and  the  patients 
complained  of  tenderness  and  pain  when  pressure  was  made  over  the 
colon. 


Fij^    107. — Parasites  (balantidic)  in  mucosa.     (After  Strong.) 

Bowman,  who  has  studied  clinically  10  cases,  3  of  which  came  to 
autopsy,  says:  "There  is  nothing  to  distinguish  the  late  ulcerations 
caused  by  amcbae  from  those  caused  by  the  Balantidium  coli,  though 
the  early  amebic  ulcers  appear  to  be  sometimes  more  punctate  in 
character." 

Balantidia,  either  alone  or  in  conjunction  with  other  organisms. 
have  the  powder  of  penetrating  the  intestinal  wall  in  some  manner,  for 
they  have  been  encountered  free  in  the  intestinal  mucosa,  submucosa, 
muscular  coat  (Figs.  105,  106),  and  peritoneal  tunic  (rarely),  but  they 
are  met  with  much  more  freciucntly  and  in  larger  numbers  in  the  sub- 
mucosa than  elsewhere,  and  are  surroimded  with  small  cell  infiltration 
and  eosinophils  abound  in  large  numbers. 

Apparently,  balantidia  can  penetrate  the  normal  mucous  mem- 
brane, but  it  is  reasonable  to  suppose  that  they  more  quickly  and 
easily  reach  the  deeper  layers  of  the  I)()wel  when  the  ei~)ithelium  has 


454 


PROTOZOAL    (parasitic)    COLITIS,    DIARRHEA    IN 


already  been  disturbed  or  broken  by  catarrhal  or  other  intestinal 
lesions  prior  to  their  coming  in  contact  with  them.  Strong  holds  that 
the  penetrating  action  of  balantidia  is  chiefly  mechanical,  and  that 
their  progress  is  closeh-  followed  b\-  pathogenic  bacteria  which  cause 
necrosis. 

Balantidia  have  also  been  found  in  large  num.bers  in  the  intestinal 
blood-vessels,  which  are  dilated  and  cause  hemorrhagic  areas,  and  re- 
liable investigators  incline  to  the  belief  that  they  may  be  transported 
to  the  li\er  and  other  organs  through  the  lymph-channels ,  because 
parasites  apparently  identical  with  them  have  been  discovered  in 
liver  abscesses,  and  it  has  been  demonstrated  that  they  frequently 
reach  the  glands  of  Liel)erkuhn  (Fig.  1 08). 


Fig.  108. — Parasite  (Balantidium  coli)  passing  through  walls  of  a  gland  of  Lieberkiihn. 

(After  Strong.) 


"Where  many  of  them  are  gathered  together  in  the  subglandular 
tissue,  a  surrounding  zone,  consisting  of  plasma-cells  and  lymphocytes, 
is  found,  with  an  abnormal  ninnber  of  eosinophils,  but  with  very  few 
polymorphonuclear  leukocytes  present.  On  the  other  hand,  the  cellu- 
lar constituents  of  the  necrotic  material  covering  the  ulcer  consists 
largely  of  polymorphonuclear  leukoc^'tes.  This  fact  would  seem  to 
indicate  that  the  parasite,  on  first  entering  the  tissue,  causes  a  low- 
grade  inflammation  independent  of  any  bacteria  which  it  may  have 
carried  with  it.  The  intestinal  bacteria  are  the  terminal  invaders  and 
cause  necrosis  of  the  tissue  already  imdermined  and  weakened  by  the 
balantidia.  Undoubtedly  many  of  the  primary  ulcers  are  caused  by 
organisms  entering  the  glandular  laxer.  but,  having  once  entered, 
ulceration  may  be  the  result  of  another  process.     On  studying  sections 


SYMPTOMS  455 

quite  remote  from  any  ulceration  and  ihout^h  apparently  uninjured 
mucosa,  the  organism  may  be  found  invading  the  submucosa  and 
muscular  strata,  while  in  the  mucous  layer  none  are  found.  Where 
they  are  found  singly  there  may  be  no  evidence  of  inflaminatory 
reaction,  but  in  other  areas,  where  several  of  them  are  gathered  to- 
gether, there  meiy  be  many  round  cells  forming  a  surrounding  zone,  and 
in  still  other  situations  marked  evidence  of  inflammatory  reaction. 
In  a  study  of  many  sections  all  stages  in  this  intiammatory  process 
may  be  seen.  From  the  single  balantidium,  which  seemingly  has 
pushed  itself  mechanically  through  the  tissue  w^ith  little  cell  reaction, 
to  groups  of  the  parasites  with  surrounding  zones  of  lymphocytes  and 
plasma-cells  w'hich  have  infiltrated  the  mucosa  itself,  demonstrating 
a  reaction  which,  with  the  invasion  of  intestinal  bacteria,  will  terminate 
in  ulceration. 

"The  organisms  may  enter  the  mesenteric  lymph-glands  and  cause 
necrosis.  In  one  of  many  cases  they  were  found  very  numerous  in 
one  of  the  sectional  glands,  and  there  was  some  increase  in  the  poly- 
morphonuclear elements  present,  but  no  bacteria  cotild  be  demon- 
strated and  there  was  no  evidence  of  tuberculosis.  If  the  organism 
can  invade  the  mesenteric  lymph-glands,  invasion  of  the  lungs  and 
liver  w^ould  seem  much  more  prol^able"  (Bowman). 

Symptoms. — The  manifestations  of  balantidic  colitis  (dysentery) 
come  on  slowly,  and  are  similar  to  those  of  other  forms  of  dysenteric 
colitis;  consecjuently,  it  is  frequently  impossible  to  distinguish  betw^een 
them.  The  disease  is  nearly  always  chronic  when  recognized,  because 
the  disturbances  at  the  inception  of  the  infection  are  mild  and  the 
nature  of  the  ailment  is  not  suspected,  in  consequence  of  which  the 
stools  are  rarely  examined.  At  first  balantidia  incite  a  catarrhal 
colo proctitis,  accompanied  by  an  increased  number  of  evacuations 
containing  an  af^normal  amount  of  mucus  and  often  undigested  food. 

Shortly  the  patient  begins  to  suffer  from  alternating  attacks  of 
diarrhea  and  constipation,  which,  in  turn,  are  followed  by  intermittent 
diarrheal  crises  characterized  by  frec|uent  fluid  evacuations  and  a 
considerable  amount  of  pus  and  some  blood  in  the  dejecta.  In  ne- 
glected ceises  the  attacks  become  more  frequent  and  severe,  and  event- 
ually the  patient  presents  the  dysenteric  symptom-complex — viz.,  fre- 
quent bloody  movements  containing  mucus,  with  tenesmus,  abdominal 
soreness,  and  pain  on  pressure  (particularly  along  the  colon),  anorexia, 
loss  of  weight,  and  digestive  disturbances  which  continue  during  acute 
attacks,  manifestations  w'hich  almost  completely  subside  in  the 
inter\als  between  the  crises. 

The  attacks  gradually  become  more  fre(|uent  and  severe  as  the 
disease  progresses,  and  after  several  months  the  stools  become  ver>' 
numerous,  offensive,  and  are  composed  chiefly  of  blood  (pure  or  in 
clots),  mucus,  pus,  and  debris  consisting  of  necrotic  tissue.  By  this 
time  the  patient  is  in  a  deplorable  condition,  and  usually  suffers 
markedly  from  mental  and  bodily  exhaustion,  emaciation,  anemia, 
palpitation,    indigestion,    abdominal    discomfort    and    pain,    \er\-    fre- 


456 


PROTOZOAL    (parasitic)    COLITIS,    DIARRHEA    IN 


(lueiit  evacuations,  colic,  distressing  tenesmus,  occasionally  edema  of 
the  feet  and  ankles,  and  nausea  or  vomiting  which  are  marked  and 
complicated  by  abdominal  distention  in  the  presence  of  perforation 
and  peritonitis. 

Necropsies  upon  patients  who   ha\e  died    from   balantidic  colitis 
(dysenter>0  have  in  different  cases  shown  the  bowel  in  various  states — 
viz.,  congested  from  catarrhal  inflaynmation.  partially  covered  with  diph- 
theric patches,  and  extensively  involved  l)\-  ulceration  (Fig.  109),  varia- 
tions which  the  author 
believes   to  represent 
stages  of  the  disease 
under  varying  condi- 
tions rather  than  dif- 
ferent types  of  infec- 

^1        lin  tA-'^'fe'         ■  "9    *  Balantidia  are  usu- 

*        -^^       '        ^'    ^       -    ^  ^lly    discoverable    in 

the  dejecta  while  diar- 
rhea prevails,  and  the 
number  present  seem 
to  licar  a  direct  rela- 
tion to  the  severity  of 
the  attack,  but  the 
stools  contain  few  or 
no  organisms  during 
the  quiescent  periods 
of  the  disease. 

Leukocytes  may  or 
may  not  be  present, 
but  eosinophilia  char- 
acterizes the  disease, 
which  in  some  cases 
is  partially  accounted 
for  by  complicating 
helminths. 

Liver  abscesses, 
adhesive  pleuritis,  and 
enlarged  mesenteric 
lymph-nodes  have  also 
complicated  the  affec- 
tion. 
Diagnosis. — Balantidic  ulcers  can  be  plainly  inspected  through  the 
sigmoidoscope,  but  it  is  often  impossible  to  differentiate  the  lesions 
from  those  of  other  types  of  specific  infections  or  colitis,  consequently 
the  diagnosis  depends  mainly  upon  a  careful  macroscopic  and  mi- 
croscopic examination  of  the  dejecta,  which  will  reveal  the  balantidia 
and  should  complete  the  diagnosis  in  the  absence  of  entamebic,  hel- 
minths, and  Shiga's,  Flexner's,  Strong's,  etc.,  bacilli. 


Fig.  109. — Photograph  of  colon  sho\\'ing  ulceration  due  to 
infection  with  Balantidium  coli.     (After  Bowman.) 


COCCIDIA 


457 


The  prognosis  of  balantidic  dysentery  (colitis)  is  not  good  in  any 
stage  of  the  disease,  and  is  very  unfavorable  in  chronic  cases  where  the 
bowel  tunics  have  become  extensively  involved,  and  the  disease  more 
often  terminates  fatally  than  either  bacillary,  entamebic,  or  helmin- 
thic colitis   (dysentery). 

An  analysis  of  the  statistics  concerning  balantidic  colitis  indicates 
that  the  mortality  in  this  affection  is  about  30  per  cent.,  but  this 
mortality  is  evidently  high,  since  the  affection  in  many  instances  was 
complicated  by  other  more  or  less  serious  diseases.  The  percentage 
of  permanent  cures  was  approximately  the  same  (30  per  cent.),  and 
slight  or  marked  temporary  improvement  occurred  in  the  remain- 
ing cases.  Naturally,  a  good  many  patients  afiflicted  with  l)alantidic 
colitis  arc  very  weak  and  frequently  attacked  by  one  of  the  acute 
diseases,  which  may  cause  their  death. 

Treatment. — The  therapeutic  indications  in  balantidic  are  prac- 
tically the  same  as  those  employed  in  the  treatment  of  entamebic 
colitis  (dysentery)  discussed  in  Chapter  XXXII,  to  which  the  reader 
is  referred. 

COCCIDIA 

Parasitic  sporozoa  are  frequently  found  in  the  blood  and  intestines 
of  cattle,  rabbits,  dogs,  cats,  pole-cats,  rats,  mice,  and  occasionally  in 
the  human  alimentary  tract.  Three  species  of  coccidia  have  been 
observed  in  man,  viz.,  Coccidiiim  ciiniculi,  C.  hominis,  and  C.  bigemi- 
num.  These  organisms  have  often  been  discovered  in  the  feces  or 
intestinal  epithelium  by  investigators  of  entamebic,  bacillary,  and  other 
forms  of  infectious  colitis,  and,  while  their  pathogenicity  in  diarrheal 
affections  has  not  been  positi\ely  proved,  there  is  every  reason  for 
believing  that  they  bear  a  causal  relation  to  such  affections,  and  if  not, 
they  at  least  aggravate  them. 

Infection  is  accomplished  by  contaminated  food,  inhalation,  and 
the  bite  of  insects. 

The  symptoms  consequent  upon  parasitic  coccidia  are  anorexia, 
emaciation,  fever,  diarrhea,  with  or  without  blood  and  mucus  in  the 
stools,  and  sometimes  a  yellowish  mucoid  nasal  and  buccal  discharge 
(in  animals). 

The  diagnosis  of  diarrhea  from  this  source,  in  the  absence  of  other 
causes,  is  based  upon  finding  coccidia  in  the  stools,  intestinal  epithe- 
lium, gall-ducts,  or  liver. 

Coccidia  have  been  mistaken  for  the  eggs  of  parasitic  worms,  but, 
as  a  rule,  they  are  easily  recognized  by  their  ovoid  form,  liberal  dimen- 
sions, and  punctate  depression  at  one  or  the  other  extremity. 

According  to  Brown,  Coccidium  cunicidi  measures  from  40  to  50  ju 
in  its  long,  and  from  22  to  2<S  ix  in  its  short,  diameter,  and  C.  hominis, 
from  25  to  30  by  15  to  20  ju. 

If  the  reader  wishes  further  knowledge  concerning  the  classification, 
habits,  and  morphology  of  coccidia,  he  can  find  it  in  Brown  and 
Luhe's  "Practical  Parasitology,"  and  Park's  "Pathogenic  Bacteria 
and  Protozoa." 


CHAPTER   XXXIX 

GONORRHEAL   COLITIS   AND  PROCTITIS   riNTESTINAL 
GONORRHEA ,   DIARRHEA   IN 

Gonorrheal  inflammation  involves  the  colon  and  rectum  more 
often  than  is  generally  supposed,  is  encountered  in  women  and  chil- 
dren more  frequently  than  in  men,  occurs  in  the  various  walks  of 
life  and  in  all  lands,  but  is  obsersed  more  often  in  Europeans  and 
Asiatics  than  in  Americans  because  a  greater  percentage  of  the  former 
are  pederasts. 

Gonorrhea  here  as  elsewhere  is  caused  by  the  gonococcus  of  Xeisser, 
and  the  anal  or  rectal  mucosa  first  becomes  infected,  from  whence  the 
inflammaton,-  process  extends  upward  to  the  sigmoid  flexure  and 
colon. 

In  75  per  cent,  or  more  of  the  cases  the  infection  is  limited  to  the 
anal  canal,  rectum,  or  sigmoid  flexure,  is  acute,  and  accompanied  by 
frequent  evacuations  and  marked  tenesmus.  Chronic  diarrhea  may 
be  a  sequel  of  gonorrheal  proctitis,  but  under  such  circumstances 
the  stools  rarely  contain  gonococci,  and  frequent  movements  are 
incident  to  catarrhal  inflammation  or  ulcers  started  by  the  original 
and  continued  by  secondar\-  or  mixed  infection. 

On  account  of  the  close  relation  between  the  anus  and  vagina,  and 
the  careless  manner  with  which  individuals  having  gonorrheal  ure- 
thritis or  vaginitis  care  for  themselves  (particularly  the  fingers),  it  is 
remarkable  that  the  rectum  is  not  more  frequently  infected  when  they 
scratch  or  wipe  the  anus.  The  author  has  treated  many  adults  for 
gonorrheal  proctitis  contracted  in  the  latter  way,  handled  3  men, 
admitted  pederasts,  who  caught  the  disease  during  rectal  intercourse, 
and  has  treated  6  children  (2  boys  and  4  girls)  for  gonorrheal  colitis 
(diarrhea)  infected  by  nurses  or  governesses. 

Pathology. — The  pathologic  changes  of  the  mucosa  in  gonorrheal 
coloproctitis  are  less  serious  than  those  of  tubercular,  syphilitic,  enta- 
mebic.  or  bacillan,-  colitis  because  the  ravages  of  mixed  infection  are 
less.  In  these  cases  the  mucous  membrane  within  the  infected  zone 
is  ver\"  highly  inflamed,  sensitive,  greatly  swollen,  often  edematous, 
smeared  over  with  foul-smelling  pus,  and  occasionally  marked  by  ero- 
sions, but  is  seldom  extensively  ulcerated. 

The  symptoms  of  gonorrheal  difter  from  those  of  other  types  of 
coloproctitis  in  that  the  manifestations  complained  of  are  located 
chiefly  in  the  lower  bowel.  During  the  acute  stage,  tenesmus,  burning 
pain,  and  sensations  of  weight  and  fulness  in  the  rectum  are  constant, 
and  the  patient  has  a  never-ending  desire  to  stool,  which  is  not  relieved 
by  an  evacuation.  The  movements  are  occasionally  mushy  or  semi- 
458 


TREATMENT 


459 


solid,  but,  as  a  rule,  they  are  lluid,  loul  sinellin,^,  and  composed  almost 
entirely  of  thick  yellow  pus  and  nuuiis.  The  acute  manifestations 
usually  modify  and  quickly  disappear  without  leaving  setiuela-  under 
the  treatment  outlined  below. 

Diagnosis. — (Gonorrheal  coloproctitis  can  be  diagnosed  by  the  acute 
symi)tonis  characterizing  the  inflammation,  inspecting  the  highly  con- 
gested and  edematous  rectal  mucosa  through  the  proctoscope,  and 
finding;  i^onococci  in  the  discharge  or  feces. 

Treatment. — (ionorrheal  coloproctitis  can,  in  the  average  case,  be 
quickly  relieved  and  curc'<l  l)y  keeping  the  patient  in  bed,  restricting 
him  to  a  fluid  or  semisolid  diet,  applying  ice  to  the  spine,  and  frequently 
irrigating  the  colon  and  rectum  with  a  hot  (ioo°  to  iio°  F.)  ichthyol, 
permanganate  of  potassium,  balsam  of  Peru  (i  jDcrccnt.),  or  argyrol 
(5  per  cent.)  solution. 

When  he  complains  bitterly  of  pain  in  the  rectum,  spasmodic  con- 
traction of  the  external  sphincter  and  levator  ani  muscles,  or  difiicult 
micturition,  the  insertion  of  a  suppository  containing  morphin  or  co- 
cain,  gr.  I  (0.008),  and  belladonna,  gr.  |  (0.015),  brings  immediate 
relief.  In  addition,  much  can  be  done  for  the  patient's  comfort  and 
diminishing  the  inflammation  by  injecting  a  hot  emulsion  composed  of 
olive  oil,  oiij  (90.0),  and  bismuth,  5ss  (2.0),  nightly.  The  warm  oil 
soothes  the  mucosa  and  cjuiets  the  irritable  muscles,  and  the  bismuth 
forms  a  coating  over  the  mucosa  and  protects  it  from  the  feces,  dis- 
charge, and  toxins. 

As  the  acute  manifestations  become  less  troublesome  the  patient 
may  be  permitted  to  go  about  and  resume  a  mixed,  non-irritating, 
regular  diet,  but  the  irrigations  should  be  continued  at  short  or  longer 
intervals  until  diarrhea  ceases,  gonococci  disappear  from  the  stools, 
and  evidences  of  the  inflammation  are  no  longer  \  isible  through  the 
proctoscope. 

A ppendic ostomy  and  cecostomy,  useful  in  the  more  malignant  types 
of  specific  colitis,  are  not  required  here,  except  in  rare  instances  where 
a  catarrhal  inflammation  or  ulcers  of  the  mucosa  remain  after  the 
gonorrhea  has  been  cured. 


CHAPTER  XL 

MYXORRHEA    COLI,    MYXORRHEA    MEMBRANACEA    MYX- 
ORRHEA  COLICA,   DIARRHEA   IN 

MEMBRANOUS  ENTERITIS  AND  COLICA  MUCOSA 

HISTORY.    GENERAL    REMARKS.    ETIOLOGY.    PATHOLOGY.    SYMPTOMS. 
DIAGNOSIS.    TREATMENT 

It  is  difficult  to  define  membranous  colitis  and  mucous  colic  be- 
cause they  are  not  diseases,  but  a  symptom-complex,  characterized  by 
copious  periodic  mucous  discharges,  abdominal  discomfort,  or  cramps 
and  constipation  (spastic),  characteristics  which  vary  greatly  in  differ- 
ent cases  and  under  varying  circumstances,  and,  finally,  because  the 
same  patient  may  at  one  time  seek  relief  from  mucous  colic,  or  at  an- 
other from  excessive  mucomemhranous  evacuations. 

Myxorrhea  coli  occurs  more  frequently  in  women  and  in  asthenic 
individuals  than  laborers,  but  is  exceedingly  rare  in  the  very  old  and 
young. 

The  nomenclature  of  these  conditions  is  confusing,  and  authorities 
of  repute  have  coined  more  than  twenty  captions  to  indicate  their 
interpretation  of  mucous  colic  and  membranous  colitis — viz. :  mem- 
branous enteritis  (DaCosta),  colica  mucosa  (Nothnagel),  tubular 
diarrhea  (Mason  Good),  pseudomembranous  enteritis  (Cruvelhier  and 
Laboulbene),  myxoneurosis  coli  (Ewald),  myxorrhea  (neurosa)  coli 
(Albu),  mucous  disease  (Whitehead),  intestinal  neurosis  (Siredey), 
croupous  enteritis,  mucous  croup,  and  colitis  pseudomembranacea,  etc. 

Owing  to  the  fact  that  mucus  responsible  for  these  conditions  is 
secreted  or  collects  within  the  colon,  and  to  eliminate  the  confusion 
which  exists  concerning  the  nomenclature  of  so-called  membranous 
enteritis  and  colica  mucosa,  the  writer  suggests  that  the  caption 
myxorrhea  coli  be  applied  to  all  mucous  stools,  myxorrhea  membra- 
nacea  to  evacuations  characterized  by  strings,  strips,  or  bowel-like 
membranous  mucous  casts,  and  myxorrhea  colica  to  mucoid  collec- 
tions including  colic.  Then,  by  adding  the  prefix  ''myxorrhea''  to  the 
factor  responsible  for  the  hypersecretion  or  retention  of  mucus,  myxor- 
rhea coli  could  be  classified  as  follows,  viz.,  Myxorrhea  catarrhal  is,  M. 
constipativa  (e.  const ipatione),  M.  spastica  (enterospasm),  M.  traumatica, 
M.  infectiosa,  M.  dyspeptica,  M.  toxica,  M.  obstructiosa,  M.  nervosa, 
M.  oroanosa,  and  M.  parasitica,  etc. 

Etiology. — Formerly,  eiuthors  attributed  myxorrhea  colica  and 
myxorrhea  membranacea  to  neuroses  which  led  to  the  hypersecretion  of 
mucus,  and  later  Nothnagel  claimed  they  might  be  caused  by  neuroses 
460 


ETIOLOtiV  461 

or  inic'slinal  catarrh,  bill  ilu'sc  in.iuitestations  may  also  be  incluced  by 
a  variety  of  conditions  and  experimentally. 

Clinicians  agree  that  nervous  phenomena — viz.,  hysteria,  neuras- 
thenia, melancholia,  and  trophoneurosis — are  frequently  observed  in 
persons  who  suffer  from  myxorrhea  colica  and  myxorrhea  mem- 
branacea,  and  the  author  is  willing  to  concede  that  organic  or  func- 
tional nervous  affections  or  psychic  disturbances  ma\'  induce  or  aggra- 
vate them. 

The  chief  claims  in  fa\'or  ot  I  he  neurotic  origin  (jf  m\-xorrhea  mem- 
branacea  and  myxorrhea  colica  are  based  upon  the  nervousness  of 
such  patients  and  the  apparently  normal  appearance  of  the  mucosa 
which  frequently  obtains  during  life  and  at  autopsy  in  such  cases. 

The  author  offers  the  following  argument  to  pro\-e  that  mucous 
colic  and  membranous  colitis  are  frequently  produced  in  other  ways, 
viz.: 

(i)  Few  patients  afflicted  with  insanity,  hysteria,  melancholia,  or 
other  nerv^ous  affections  suffer  from  myxorrhea  coli. 

(2)  Mucous  discharges  may  occur  independently  or  complicate 
nervous  diseases. 

(3)  Myxorrhea  colica  and  myxorrhea  membranacea  may  obtain 
for  years  without  the  patient  becoming  nervous. 

(4)  Frequently  neurogenic  disturbances  do  not  appear  until 
months  or  years  after  the  onset  of  myxorrhea  coli. 

(5)  Correction  of  associated  neurogenic  disturbances  often  fail, 
while  therapetitic  measures  directed  against  local  or  general  disease 
causing  intestinal  irritation  succeeds. 

(6)  The  frequency  of  m\xorrhea  membranacea  and  colica  in  women, 
and  the  fact  that  they  are  usually  encountered  between  the  twentieth 
and  forty-fifth  years,  indicate  that  abnormal  menstruation  sometimes 
influences  the  hypersecretion  of  mucus. 

(7)  Atonic  or  spastic  constipation  usually  precede  or  accompany 
mucous  stools,  and  are  probably  a  factor  in  their  causation,  since  they 
frequently  cease  when  regular  evacuations  are  established. 

(8)  Copious  discharges  of  membranous  or  jelly-like  mucus  with 
and  without  colic  follow  frequent  or  prolonged  alum,  silver  nitrate, 
copper  sulphate,  mercury,  tannic  acid,  glycerin,  and  iodin  colonic 
irrigation. 

(9)  It  has  been  demonstrated  experimentally  that  the  secretion  of 
mucus  can  be  augmented  by  iodin,  silver  nitrate,  or  alcohol  applica- 
ti(jns  to  the  intestinal  mucosa,  reflex  action  through  other  organs  or 
the  solar  plexis,  and  injecting  rabbits  with  sodium  oxalate,  subjecting 
them  to  infection,  having  them  eat  indigestible  food,  and  stimulating 
the  intestinal  nerv^es  with  electric  currents. 

(10)  Patients  suffering  from  myxorrhea  coli  usually  h.ive  previously 
suffered  from  gastro-intestinal  or  systemic  disturbances. 

(11)  Owing  to  the  similarity  of  mucous  discharges  in  intestinal 
catarrh  and  mucomcmbranous  colitis  it  is  often  impossible  to  dis- 
sociate them. 


462   MYXORRHEA  COLI,  MEMBRANACEA,  COLICA,  DIARRHEA  IN 

(12)  Mucus  may  be  constant  in  colitis,  but  when  mucous  stools 
appear  periodically,  colic  ensues,  and  the  mucoid  discharges  are  mem- 
branous, it  indicates  that  myxorrhea  colica  or  myxorrhea  membran- 
acea  are  secondary  to  intestinal  catarrh. 

(13)  Mucomembranous  evacuations  and  colic  have  followed  fer- 
mentation and  putrefaction,  and  very  likely  are  caused  by  excessively 
active  colon  bacilli  or  other  intestinal  micro-organisms  or  their  toxins. 

(14)  Myxorrhea  membranacea  and  myxorrhea  colica  are  occa- 
sionally associated  with  intestinal  helminths  which  irritate  the  mucosa. 

(15)  Intestinal  stasis  and  auto-intoxication  frequently  complicate 
myxorrhea  membranacea  and  myxorrhea  colica  and  probably  cause 
them  in  some  cases. 

(16)  Myxorrhea  colica  and  myxorrhea  membranacea  are  occa- 
sionally manifestations  of  foreign  bodies  (intestinal  sand,  enteroliths, 
bismuth  accumulations,  and  scybala)  which  traumatize  the  intestine. 

(17)  Colonic  coprostasis  is  accompanied  by  nerv-e  phenomena  and 
mucous  evacuations,  which  disappear  when  it  has  been  corrected. 

(18)  The  expulsion  of  jelly-like  or  inspissated  mucus  is  not  charac- 
teristic of  particular  affection,  but  is  a  reactionary  phenomenon,  occur- 
ring under  varying  conditions,  and  Tremoliere  says,  "Mucous  stools 
do  not  represent  a  specific  factor  more  than  does  mucous  sputum  a 
specific  disease  of  the  respiratory  tract." 

(19)  Mucous  colic  and  membranous  colitis  may  be  secondar\^  to 
defective  metabolism  in  phlegmatic  or  nervous  individuals. 

(20)  It  has  been  demonstrated  by  bowel  inspection  that  myxorrhea 
colica  and  myxorrhea  membranacea  may  be  induced  by  organic 
changes  in  the  mucosa. 

(21)  Finally,  it  is  sometimes  difficult  to  determine  whether  myxor- 
rhea coli  is  dependent  upon  affections  of  the  nerves,  systemic  disturb- 
ance, inflamed  mucosa,  or  obstructing  lesions,  because  one  or  all  may 
be  factors  in  the  same  case  and  produce  the  symptom-complex  of  myxor- 
rhea coli. 

The  author  has  treated  patients  for  myxorrhea  coli  where  multiple 
and  widely  varying  factors  played  a  part  in  its  production,  hence  he 
is  constantly  on  the  lookout  for  more  than  one  cause. 

Myxorrhea  coli  not  infrequently  complicates  atrophy  and  atony 
of  the  large  intestine,  and  has  suddenly  appeared  during  and  following 
diphtheria,  scarlet  fever,  measles,  ptomain-poisoning,  influenza,  typhoid 
fever,  chemical  poisoning,  and  disturbances  of  the  liver,  gall-bladder, 
pancreas,  and  kidneys. 

Gastrogenic  disturbances  (achylia  gastrica,  hyperchlorhydria,  and 
cancer)  which  unbalance  the  secretion,  lead  to  its  stagnation,  or  inter- 
fere with  gastric  motility,  occasionally  lead  to  mucomembranous 
colitis,  and  myxorrhea  coli  has  accompanied  enterogenic  disturbances 
which  modify  the  siicciis  entericus. 

Frequently,  my.xorrhea  colica  and  m\xorrhea  membranacea  are 
symptoms  of  catarrhal,  syphilitic,  tubercular,  balantidic,  entamebic, 
coccidic,  flagellate,  bacillary,  helminthic,  and  other  types  of  colitis. 


ETIOLOGY  463 

Myxorrhea  coli  may  also  be  induced  by  scybala,  purgation,  irri- 
tating drugs,  enteroclysis,  rriassage,  vibratory  treatments,  or  anything 
which  irritates  or  intlames  the  mucosa  or  causes  constipation,  intestinal 
obstruction,  enterospasm  or  fecal  retention,  and  has  been  known  to 
follow  rough  handling  of  the  intestine,  abdominal  viscera,  and  pelvic 
organs  during  operation  and  careless  introduction  of  the  sigmoidoscope. 

Individuals  afflicted  with  myxorrhea  membranacea  and  myxorrhea 
colica  have  a  lowered  vitality,  are  under  weight,  act  slowly,  and  fre- 
quently suffer  from  anomalies  of  the  teeth,  nails,  or  hair,  movable 
kidneys,  enteroptosis,  uterine  procidentia,  hemorrhoids,  varicose  veins, 
hernia,  insufficiency  of  the  tissues  (connective,  ner\'ous,  and  muscular), 
and  nutritional  trophic  disturbances  of  the  lymphoid  and  mucous 
glandular  mechanism  (adenoidism). 

Rhinopharyngeal  lesions  (vegetations,  etc.)  and  intestinal  disorders 
compose  the  symptom-complex  of  adenoidism  obser^-ed  in  thyroid 
disease,  which  is  an  important  factor  in  myxorrhea  membranacea  and 
myxorrhea  colica.  Tremoliere  holds  that  atrophy  and  hypertrophy 
of  the  thyroid  gland  are  frequently  associated  with  myxorrhea  coli, 
and  when  they  are  not,  the  liver,  kidney,  or  some  other  organ  is  in- 
volved and  causes  faulty  metabolism,  malnutrition,  or  trophic  changes, 
and  myxorrhea  membranacea  or  myxorrhea  colica. 

Myxorrhea  membranacea  and  myxorrhea  colica  may  be  aggravated 
or  caused  by  any  of  the  following  surgical  diseases  or  conditions — viz., 
congenital  deformities  of  the  bowel,  foreign  bodies,  relaxed  abdominal 
•walls,  movable  cecum,  splanchnoptosis,  malignant  and  non-malignant 
neoplasms,  peritonitis,  appendicitis,  salpingitis,  diverticulitis,  peri- 
colitis, adhesions,  tumefactions,  invagination  {inttisstisception) ,  volvu- 
lus, extra-intestinal  pressure,  stricture,  angulation.  Lane's  kink,  abdom- 
inal aneurysm,  rectocele,  diseased  or  displaced  neighboring  organs, 
mesenteric  disturbances,  hernia,  cholelithiasis,  enterospasm,  obstruction 
by  intestinal  parasites,  procidentia  recti,  hypertrophy  of  O'Beirne's 
sphincter,  the  rectal  valves,  levator  ani,  and  sphincter  muscles,  deviated 
coccyx  and  rectal  affections  {hemorrhoids,  ulcers,  or  fissures). 

The  above  diseases,  singly  or  collectively,  lead  to  the  hypersecre- 
tion of  mucus  because  they  narrow,  block,  or  immobilize  the  intes- 
tine, interrupt  peristalsis,  induce  obstipation  and  fecal  impaction, 
augment  pathogenic  bacteria  and  their  toxins,  induce  inflammatory 
and  ulcerative  lesions  in  the  bowel,  irritate  the  mucosa,  stimulate  the 
secretorv'  and  motor  nerv^es  to  excessive  activity,  favor  intestinal  auto- 
intoxication, or  retain  feces  and  discharges  until  they  become  oftensive 
and  irritating. 

Constipation  may  be  congenital  or  appear  earl\-  in  life  and  nearly 
always  is  a  complication  of  mucous  colic  and  membranous  colitis,  hence 
the  author  believes  these  conditions  are  often  caused  by  mechanic 
intestinal  defects  which  lead  to  fecal  retention.  I'ndcr  such  circum- 
stances, owing  to  the  small  amount  of  food  ingested  by  infants  and 
young  children,  no  trouble  ensues  in  the  beginning,  but  later,  when  the 
diet  is  liberal,  the  feces  are  more  bulky,  they  pass  the  obstruction  with 


464        MVXORRHEA    COLI,    MEMBR.\NACEA,    COLICA.    DIARRHEA    IN 

difficulty,  Stagnation  takes  place,  and  a  hypersecretion  of  mucus 
ensues. 

The  writer  has  observed  myxorrhea  coli  in  a  boy  of  three,  a  girl 
of  five,  and  in  six  other  children  under  twelve  years  of  age,  who  suffered 
from  postoperative  sequelae  where  attempts  had  been  made  to  correct 
congenital  deformities  of  the  colon,  rectum,  or  anus. 

In  studying  the  etiolog\-  of  myxorrhea  coli  one  should  keep  in  mind 
the  relation  of  the  colon  to  the  diaphragm,  kidney,  liver,  stomach, 
uterus,  adnexa,  bladder,  and  prostate,  because  the  bowel  is  often  dis- 
placed by  neighboring  organs  or  becomes  involved  through  the  ex- 
tension of  disease  from  them. 

Splanchnoptosis  (enteroptosis,  coloptosis,  nephroptosis,  hepatopto- 
sis.  and  gastroptosis )  is  frequently  associated  with  and  evidently  causes 
myxorrhea  colica  and  myxorrhea  membranacea,  because  stools  and 
colic  usually  disappear  when  the  organs  have  been  replaced  and 
anchored. 

Appendicitis,  peritonitis,  pericolitis,  diverticulitis,  abdominal  and 
pelvic  suppurations,  typhoid  fever,  and  colitis  frequently  lead  to 
myxorrhea  coli  because  they  favor  the  formation  of  exudates,  bandular, 
broad  or  encircling  adhesions  or  pseudoperitoneal  membranes,  which 
agglutinate  or  bind  the  gut  to  neighboring  organs  or  the  parietes,  twist, 
angulate  or  press  upon  it.  and  lead  to  colonic  irritability,  fecal  retention, 
and  the  hypersecretion  of  mucus. 

Three  times  the  author  has  cured  m^-xorrhea  coli  by  remo\"ing 
bismuth  accumulations  from  the  colon  or  rectum,  and  has  many  times 
arrested  mucoid  evacuations  by  clearing  the  gut  of  scybala  and  fruit 
stones,  seeds,  or  skins. 

The  writer  has  a  record  of  more  than  200  patients  operated  upon 
for  constipation  induced  by  chronic  invagination  of  the  sigmoid  flexure 
into  the  rectum,  of  whom  25  per  cent,  suffered  from  myxorrhea  colica 
or  myxorrhea  membranacea.  and  the  majority  of  these  sufferers  were 
speedily  relie\"ed  or  cured  by  sigmoidopexy.  The  frequency  with 
which  women  suffer  from  mucomembranous  colitis,  and  the  good  re- 
sults which  follow  the  extirpation  of  uterine  tumors,  diseased  tubes 
and  ovaries,  and  the  correction  of  uterine  displacements,  demonstrates 
that  female  genital  disturbances  may  cause  myxorrhea  coli. 

Vesical  and  prostatic  diseases  may  also  augment  the  secretion  of 
mucus  in  some  instances  by  traumatizing  the  gut  or  exciting  the 
levator  ani  muscle  to  frequent  contraction. 

In  75  per  cent,  of  the  cases  of  myxorrhea  coli  treated  by  the  writer 
the  hypersecretion  of  mucus  was  apparently  caused  by  adhesions,  an- 
gulations, invagination,  or  mechanic  bowel  defects,  inflammator\'  or 
ulcerative  lesions  of  the  colon  or  rectum,  which  increased  the  mucus 
or  caused  its  retention  until  it  became  inspissated  and  membranous. 

In  concluding  his  remarks  upon  the  etiolog\'  of  myxorrhea  mem- 
branacea and  m\xorrhea  colica  the  writer  would  reiterate  that  the 
hypersecretion  of  mucus  is  a  common  manifestation,  complicates  many 
chronic  medical  and  surgical  diseases  of  the  bowel,  and  that  the  amount. 


SYMPTOMS  465 

consistence,  and  form  of  the  mucoid  evacuations  depend  lar'^ely  upon  the 
irritable  state  of  the  intestine,  enterospasm,  shape  of  the  gut  where  the 
mucus  accumulates,  and  length  of  time  it  is  retained. 

If  internists  and  gastro-enterologists  are  aware  of  these  facts,  they 
tail  to  mention  them,  consequently  their  followers  believe  that  myxor- 
rhca  coli  (myxorrhea  membranacea  and  colica)  are  alwa\s  induced  by 
intestinal  catarrh  or  neuroses,  when  they  may  l)e  caused  b\'  many  other 
diseases  and  conditions. 

The  pathology  of  myxorrhea  coli  is  not  understood  because  it  is 
not  characterized  by  definite  lesions,  seldom  kills,  and  has  been 
studied  at  autopsy  only  a  few  times  where  it  complicated  other  fatal 
diseases.  The  author  has  observed  myxorrhea  membranacea  and 
myxorrhea  colica  in  patients  where  the  mucosa  was  inflamed  or  ulcer- 
ated and  where  it  appeared  normal.  Most  often,  however,  it  has  been 
encountered  in  individuals  who  had  been  sufTering  from  intestinal 
stasis,  fecal  impaction,  and  toxemia  induced  by  mechanic  defects  in  the 
colon  or  rectum  which  caused  fecal  retention. 

Symptoms, — Under  normal  conditions  the  amount  of  mucus  se- 
creted is  so  slight  that  it  is  difficult  to  discover  in  the  feces  with  the 
microscope,  and  when  visible  in  the  stools  it  is  being  abnormally 
secreted  and  the  patient  suffers  from  myxorrhea.  The  manifestations 
of  myxorrhea  coli  are  variable  in  ditTerent  cases  and  in  the  same  indi- 
vidual at  different  times,  but  obstinate  constipation  and  the  periodic 
evacuation  of  large  quantities  oj  mucus  or  colic  constitute  the  chief 
symptoms. 

When  hypersecretion  is  marked  and  mucus  is  long  retained,  the 
water  is  absorbed,  and  it  becomes  inspissated,  grayish  in  color,  accu- 
mulates in  a  large  mass,  or  when  compressed  it  assumes  the  form  of 
bowel  casts  or  strips,  acts  as  an  irritant,  and  excites  mild  peristalsis, 
which  favors  its  expulsion. 

Myxorrhea  colica  and  myxorrhea  membranacea  may  dominate  the 
disease  producing  them,  and  clear  jelly-like  mucous  evacuations  may 
prevail  for  weeks  or  months,  when  suddenly  a  crisis  sets  in,  the  patient 
complains  of  cramps,  and  later  the  evacuations  of  mucomembranous 
strips  or  casts.  Again,  he  may  stifTer  indefinitely  from  mucous  dis- 
charges induced  by  a  variety  of  causes  and  never  complain  of  myxorrhea 
colica  or  myxorrhea  membranacea. 

Persons  afflicted  with  myxorrhea  membranacea  and  myxorrhea 
colica  are  sometimes  bothered  with  impaired  digestion,  malaise,  melan- 
cholia, nervousness  and  abdominal  uneasiness,  disccMiifort,  soreness, 
pain  or  colic  for  a  short  while  l)eforc  mucous  stools  appear,  or  remain 
well  in  the  intervals  Ijetween  attacks  of  myxorrhea  coli. 

Strips  or  casts  of  mucus  occasionally  create  crawling  sensations 
and  are  mistaken  for  worms,  but  when  low  down  they  are  easily  located 
through  the  sigmoidoscope,  and  arc  to  be  seen  projecting  through  the 
rectosigmoidal  aperture  or  hanging  over  the  rectal  valves.  When 
mucus  becomes  dry  and  collects  in  any  form  it  causes  irritation  and 
leads  to  enterospasm   (nnxorrhea  colica),  marked  constipation,  fecal 


466       MYXORRHEA    COLI,    MEMBRANACEA,    COLICA,    DIARRHEA    IN 

impaction,  gas  distention  and  colic,  which  continue  until  it  is  evacu- 
ated through  the  sigmoidoscope  or  in  some  other  way. 

Diarrhea  may  be  noticeable  during  attacks  of  m\xorrhea  colica  or 
it  may  not  occur  until  the  obstruction  incident  to  enterospasm  has 
been  relieved,  and  the  backed-up  irritating  feces,  scybala,  discharges, 
and  toxins  find  their  wa\-  into  the  lower  bowel  and  excite  abnormal 
peristalsis  and  the  hypersecretion  of  mucus. 

Diagnosis. — Usualh-  in  obstinate  cases  of  myxorrhea  coli  the  his- 
ton,'  will  show  that  the  patient  has  been  troubled  for  weeks,  months, 
or  years  with  gastro-intestinal  disturbances,  menstrual  abnormalities, 
constipation,  psychic  or  nervous  phenomena,  disturbances  of  the 
liver,  pancreas  or  heart,  or  obstructing  lesions  of  the  gut  prior  to  the 
attack,  which  indicate  that  the  mucous  discharges  are  secondary. 

Myxorrhea  coli  is  diagnosed  with  ease  by  the  mucoid  evacuations 
(made  up  of  jelly-like  or  mucous  strings,  strips,  or  casts)  which  appear 
suddenly  following  attacks  of  nausea,  indigestion,  obstinate  constipa- 
tion, and  abdominal  uneasiness,  discomfort,  or  soreness  in  patients 
who  have  otherwise  been  comparatively  well. 

Myxorrhea  colica  must  be  differentiated  from  other  types  of  intes- 
tinal obstruction,  but  in  the  presence  of  the  enumerated  symptoms, 
violent  colic  and  the  absence  of  pus  or  blood  in  the  stools,  one  is  justi- 
fied in  diagnosing  this  condition  before  and  after  the  mucous  collec- 
tions have  been  evacuated.  When  an  acute  attack  of  m^-xorrhea  coli 
subsides  the  abdomen  and  intestine  should  be  examined  and  the  feces 
analyzed,  with  the  object  of  ascertaining  what  is  causing  the  hyper- 
secretion and  retention  of  the  mucus.  It  is  also  important  to  deter- 
mine whether  or  not  the  sufferer  is  afflicted  with  a  nervous  or  other 
affection  which  would  influence  the  myxorrhea  colica  or  myxorrhea 
membranacea. 

Treatment. — A  routine  treatment  of  myxorrhea  coli  is  impracticable, 
owing  to  its  varied  etiolog\".  and  because  the  patient  may  seek  re- 
lief from  either  m\'xorrhea  membranacea  (mucous  casts)  or  myxorrhea 
colica  (colic). 

During  acute  attacks  curative  measures  should  be  held  in  abeyance, 
for  the  patient  desires  immediate  relief  from  the  discharge  of  mucous 
casts  or  masses  or  colic  from  which  he  suifers. 

When  the  patient  seeks  a  cure,  the  writer  informs  him  that  myxor- 
rhea coli  is  a  manifestation  of  some  other  affection,  and  that,  after 
the  crisis  is  passed,  prolonged  treatment  or  an  operation  may  be 
required  to  effect  a  cure. 

Where  tenacious  mucus  collects  in  the  lower  sigmoid  or  rectum  it 
can  be  removed  with  a  blunt  scoop  or  swab  and  cotton,  following  the 
introduction  of  the  sigmoidoscope,  but  when  higher  up.  rest  in  bed.  a 
liberal  dose  of  castor  oil,  hot-water  drinking,  abdominal  fomentations, 
and  hot  high  colonic  encmata  are  indicated  to  soothe  the  mucosa  and 
cause  the  intestinal  musculature  to  relax,  which  in  turn  overcomes 
constipation,  favors  expulsion  of  the  mucus,  and  relie\es  the  patient 
mentally  and  physically. 


TREATMENT  467 

Strychnin,  gr.  ,1,  (o.ooi),  Fowler's  solution,  npv  (0.30),  extract  of 
physostigma,  gr.  j  (0.015),  hypophosphites,  Russell's  emulsion,  and 
other  nerve,  muscular,  or  general  tonics  are  indicated  when  the  sufferer 
is  nervous  or  run  down,  and  the  treatment  is  more  effective  when  sup- 
ported by  hydrotherapy,  abdominal  massage,  vil)rati(jn,  or  electricity 
when  the  bowel  is  sluggish. 

Where  the  bowel  is  sensitive,  highly  irritable,  and  enterospasm  is 
a  complication,  belladonna,  n^x  (0.60),  relieves  the  muscular  spasm,  but 
when  colic  is  severe  it  should  be  reinforced  by  codein,  gr.  |  (0.03),  or 
morphin,  gr.  j  (0.016),  administered  every  three  or  four  hours  to  arrest 
pain  and  induce  sleep. 

Between  attacks  of  m\xorrhea  mcmbranacca  and  myxorrhea  colica 
liquid  parafifin  or  albolin,  administered  in  the  morning  and  at  night 
in  liberal  doses,  5j  (60.0),  lubricate  the  intestine,  minimize  constipa- 
tion, and  favor  the  expulsion  of  mucus  i)efore  it  becomes  inspissated 
and  irritating. 

It  is  advisable  in  some  cases  to  control  the  diet,  but  a  routine  dietary 
is  impracticable  because  of  the  varied  etiology  of  myxorrhea  coli. 
During  attacks  of  myxorrhea  colica  better  and  quicker  results  are  ob- 
tained when  the  patient  eats  more  frequently  and  consumes  chiefly  hot 
fluids,  milk,  soup,  purees  and  meat  juices,  and  abstains  from  foods 
which  leave  a  large  residue. 

Following  an  acute  attack  of  myxorrhea  membranacea,  forced 
feeding  and  a  diet  composed  mainly  of  \egetables  (cellulose)  in  con- 
junction with  rest  in  bed,  after  the  plan  of  Von  Noorden,  usually  cor- 
rects constipation,  which  is  followed  by  cessation  of  the  mucomembran- 
ous  evacuations,  and  in  uncomplicated  cases  the  myxcjrrhea  does  not 
recur  while  the  patient  has  normal  movements. 

A  heavy,  coarse  diet  temporarily  causes  sensations  of  abdominal 
fulness  and  discomfort,  but  they  disappear  spontaneously.  Where 
constipation  ensues  from  overdigestion,  the  administration  of  regulin, 
pieces  of  cork,  or  seeds  increase  the  bulk  of  the  feces,  stimulate  peristal- 
sis, and  usually  bring  about  normal  evacuations. 

As  soon  as  myxorrhea  coli  and  constipation  have  been  relieved, 
the  patient  should  return  to  his  regular  diet  and  discontinue  the  regu- 
lin. A  cellulose  or  vegetable  diet  is  out  of  place  where  the  hypersecre- 
tion of  mucus  is  augmented  or  caused  by  gastrogenic,  enterogenic  or 
neurogenic  disturbances,  or  colitis,  because  it  makes  the  feces  bulky 
and  irritating  to  the  hypersensitive,  inflamed,  or  ulcerated  mucosa, 
augments  the  secretion  of  mucus,  and  has  a  tendency  toward 
enterospasm  and  colic. 

Drastic  cathartics  arc  contra-indicated  during  crises  of  mucous  colic 
because  they  cannot  drive  feces  through  the  blockefl  gut  and  increase 
the  patient's  suffering. 

Purgatives  also  do  more  harm  than  good  where  myxorrhea  mem- 
branacea or  myxorrhea  colica  arc  complicated  by  chronic  intestinal 
obstruction  from  whatever  cause,  since  they  stimulate  violent  peris- 
talsis and  do  not  secure  the  coveted  evacuation.     Under  such  circum- 


468   MYXORRHEA  COLI,  MEMBRAXACEA,  COLICA,  DIARRHEA  IN 

stances  comfortable  stools  can  be  obtained  b\-  hot-water  drinking  and 
the  administration  of  mineral  oil,  salts  in  small  repeated  doses,  tluid- 
extract  of  cascara  sagrada,  rrjixv  (i.o),  or  a  milder  dinner  pill  to  soften 
the  excreta,  or  belladonna,  niix  (0.60),  to  soothe  and  relax  the  irritable 
intestinal  musculature. 

Astringents  (tannalbin,  tannigen,  ichthoform,  and  bismuth  sub- 
gallate),  gr.  x  (0.60),  may  be  called  for  in  the  treatment  of  myxorrhea 
coli  complicating  colitis  when  diarrhea  is  troublesome,  but  should  be 
discontinued  when  the  stools  become  normal. 

When  myxorrhea  membranacea  is  associated  with  inflammatory, 
ulcerative,  or  obstructive  lesions  of  the  colon,  the  patient  can  be 
quickly  impro\ed  by  treating  the  mucosa  with  medicated  solutions 
or  oil  introduced  through  the  anus  or  through  an  appendicostomy 
or  cecostomy  opening,  which  insures  their  reaching  all  parts  of  the 
bowel. 

Long  colon  tubes  are  not  dependable  for  irrigating  purposes  be- 
cause they  double  up  in  the  sigmoid  flexure  or  rectum,  prevent  the 
solution  or  oil  from  passing  into  the  bowel,  and  cause  pain.  Medi- 
caments can  be  made  to  reach  the  upper  colon  by  placing  the  patient 
in  the  exaggerated  knee-chest  posture,  introducing  the  sigmoidoscope, 
and  pouring  the  irrigant  or  oil  directly  into  the  bowel  with  the  aid  of  a 
pitcher  and  funnel  attached  to  rubber  tubing  (Fig.  119),  or  by  invert- 
ing the  patient  and  employing  the  author's  funnel-shaped  proctoscope 
and  pitcher,  which  enables  one  to  pour  a  quart  or  more  of  solution  or 
oil  directly  into  the  colon  on  account  of  the  inflation  and  displacement 
of  the  viscera  which  ensues. 

The  author  has  experimented  with  many  irrigants  in  myxorrhea  coli 
alone  or  complicated  by  ulceration  and  diarrhea,  but  obtained  the  best 
results  from  boric  acid  (3  per  cent.),  ichthyol,  balsam  of  Peru, 
potassium  permanganate  (i  to  2  per  cent.),  and  arg\Tol  (5  per  cent.) 
irrigations,  employed  daily  or  three  times  weekly. 

When  the  mucosa  is  sensitive  and  the  musculature  highly  irrit- 
able, warm  crude  oil  containing  bismuth  should  be  substituted  for 
or  alternated  with  irrigation  because  of  its  soothing  and  healing 
action. 

In  addition,  when  the  intestine  is  obstructed  by  adhesions,  kinks, 
twists,  pericolic  membrane,  extra  bowel  pressure,  or  stricture,  etc., 
the  lesion  must  be  corrected  before  a  permanent  cure  can  be  ob- 
tained. 

In  cases  where  the  colon  is  permanently  disabled,  resection  may  be 
necessary,  but  when  the  patient  is  in  a  poor  condition  and  cannot 
withstand  a  prolonged  operation,  the  diseased  bowel  should  be  isolated 
by  entero-anastomosis,  unilateral  or  bilateral  exclusion. 

Colostomy  has  been  successfully  employed  in  the  treatment  of 
myxorrhea  coli,  but  has  been  abandoned  in  favor  of  appendicostomy, 
cecostomy,  resection,  or  intestijial  exclusion,  because  of  its  disgusting 
features  and  the  serious  secondary  operation  required  to  close  the  arti- 
ficial anus. 


PROGNOSIS  469 

The  prognosis  of  myxorrhea  membranacea  and  myxorrhea  colica 
is  very  good  when  caused  by  obstructing  lesions  of  the  colon  correct- 
able by  operation,  but  a  longer  time  is  required  to  effect  a  cure  when 
they  are  secondary  to  inflammatory  or  ulcerative  lesions  of  the  mucosa, 
and  myxorrhea  membranacea  and  myxorrhea  colica  are  more  difficult 
to  permanently  eliminate  when  the  hypersecretion  of  mucus  is  induced 
by  gastrogenic,  enterogenic  or  neurogenic  disturbances,  general  disease, 
or  atonic  constipation. 


CHAPTER   XLI 

INTESTINAL  IRRIGATION  (ENTEROCLYSIS) ;  ENEMATA  IN 
THE  TREATMENT  OF  DIARRHEAL,  INFLAMMATORY, 
AND  PARASITIC  DISEASES  OF  THE  GASTRO-INTES- 
TINAL  TRACT 

In  the  treatment  of  diarrhea  incident  to  inflammatory  and  ulcera- 
tive parasitic  lesions  of  the  intestine  of  whatever  kind,  irrigation  is 
perhaps  the  most  reliable  therapeutic  measure  at  our  command,  while 
enemata,  so  useful  in  overcoming  constipation,  play  a  minor  part  in 
these  conditions.  In  this  class  of  affections,  enemata,  large  and  small, 
are  resorted  to  principally  to  prevent  or  dislodge  fecal  impaction  where 
ulcers  have  healed  and  a  stenosis  has  formed  in  the  lower  bowel,  and 


Fig.  no. — Catheters  closed  with  Cravat  clamps.     Gant's  older  cecostomy.  which  provides 

for  two-way  irrigation. 


for  evacuating  gas,  putrefying  food-remnants,   discharges,  and  other 
irritants  within  the  rectum. 

Since  one  can  accomplish  these  purposes  by  irrigation  and  other- 
wise benefit  the  patient,  the  author  will  not  further  discuss  enemata, 
but  will  refer  the  reader  to  his  former  work,^  where  their  indication 
and  technic  of  administration  have  been  given  in  detail. 

^  Gant,  Constipation  and  Intestinal  Obstruction  (Obstipation),  p.  23c,  1909.  W.  B. 
Saunders  Co. 
470 


INTESTINAL    IRRIGATION    (eNTEROCLYSIS) 


471 


Irrigations  in  the  treatment  of  diarrhea  and  parasitic  diseases  are 
emjiloyed  chiefly  to  soothe  the  bowel,  heal  local  lesions,  prevent  the 
iornuuion  of  impacted  fecal  masses,  neutralize  or  wash  out  toxins,  re- 
move irritating  pus,  blood,  mucus,  tissue  debris  and  feces,  and  relieve 
enterospasm.  i)ain,  and  tenesmus.  In  this  connecti(jn  it  might  be  well 
to  remember  that  enemata  are  usually  given  with  the  idea  that  the\' 
arc  to  remain  until  fecal  accumulations  are  expelled,  while  irrigations 
are  administered  slowly,  so  that  the  fluid  may  be  taken  up  by  the 
system,  or  it  is  i)C'rmitted  t(^  run  into  and  out  of  the  bowel  sinuiltane- 


Fig.  III. — Hard-rubber  enema  syringe. 


ously,  with  the  object  of  immediately  cleansing  the  mucosa  and  stimu- 
lating lesions  to  heal. 

Bowel  flushing  may  be  conducted  from  below  by  way  of  the  anus, 
or  above  through  an  artificial  opening,  the  operation  for  the  making 
of  which,  according  to  its  location,  is  designated  cecostomy  (Fig.  155), 
appendic ostomy  (Fig.   164),  Gant's  cecostomy  with  an  arrangement  for 

irrigating  both  the  large  and  small  intestine 
(Fig.  156),  or  colostomy  (Fig.  170). 

In  loiv  or  rectal  irrigation  the  washing 
is  confined  to  the  terminal  extremity  of 
the  gut,  and  in  high  or  colonic  irrigation 
the  entire  large  bowel  receives  treatment. 
When  the  solution  is  made  to  enter  the  arti- 


Fig.   112. — Graduated  container  for   irri- 
gating fluids. 


Fig.  113. — Irrigating  nozzle  with  stop-cock. 


ficial  inlet  and  pass  ciuickl}-  downward  along  the  colon  and  out  at  the 
anus  the  procedure  is  designated  through-and-through  irrigation  or 
enteroclysis. 

The  older  plan  of  introducing  the  fluid  from  below  is  preferable 
where  the  solution  reaches  the  entire  diseased  area,  but  in  many  in- 
stances, for  one  reason  or  another,  this  cannot  be  accomplished,  and 
lesions  in  the  upper  portion  of  the  colon  are  not  reached  and  the 
treatment  fails.  Under  such  circumstances  through-and-through 
irrigation  should  be  immediately  proxided  for  by  one  of  the  operative 
procedures  named  above  and  fully  described  elsewhere. 

Appendicostomy  or  cecostomy   is   indicated   immediateix    in    the 


472  INTESTINAL    IRRIGATION    (eNTEROCLYSIS) 

treatment  of  persons  afiflicted  with  diarrhea  resulting  from  intestinal 
inflammation,  ulceration,  or  both,  who  come  from  a  distance  and  can 
remain  but  a  short  time,  those  who  are  exhausted  by  frequent  evacua- 
tions and  tenesmus,  or  violently  poisoned  by  retained  toxins,  and  where 
the  discharges  are  enormous,  irritating,  and  cause  auto-intoxication,  or 
hemorrhage  is  a  dangerous  complication.  This  method  of  completely 
flushing  the  large  intestine  is  more  reliable  and  effective  than  recto- 
coJonic  when  the  fluid  is  introduced  through  the  anus,  but  when  there 
is  an  enterocolitis,  Gant's  cecostomy,  with  an  arrangement  for  irrigating 
separately  or  simultaneously  the  small  incestine  and  colon,  is  indicated, 
because  lesions  in  all  segments  of  the  intestine  can  be  treated,  while 
following  appendicostomy  and  ordinary  cecostomy  the  irrigation  does 
not  reach  above  the  colon. 

The  frequency  of  the  irrigation  varies  in  different  cases,  and  must 
be  increased  or  decreased  according  to  the  condition  of  the  patient. 
WTien  the  movements  are  ver\-  frequent  (ten  to  twenty  daily),  toxemia 
is  alarming,  bleeding  profuse,  or  the  discharges  are  copious  and  foul, 
the  gut  should  be  flushed  two  or  three  times  daily  for  a  short  time, 
and  then  once  or  twice  as  these  symptoms  modify,  and,  finally,  at  the 


Fig.  114. — Metal  piston  enema  s\Tinge  and  attached  colon-tube. 

end  of  a  few  weeks,  when  the  movements  are  fewer  or  normal  and  the 
patient  has  gained  in  weight  and  strength,  his  complexion  has  im- 
proved, and  the  discharges  are  slight,  all  of  which  manifestations  in- 
dicate that  the  lesions  are  rapidly  healing,  irrigation  is  not  necessary 
more  than  once  daily  or  three  times  weekly.  It  has  been  the  author's 
practice  to  continue  the  treatment  for  several  weeks  and  sometimes 
months  following  an  apparent  cure  of  the  patient,  because  on  several 
occasions  where  flushing  was  stopped  too  soon  relapse  occurred. 

When  administering  enerymta  the  amount  of  fluid  injected  is  usu- 
allv  limited  to  2  or  3  quarts  because  of  the  distention  pain  which 
follows,  and  8  quarts,  the  full  capacity  of  the  colon  and  rectum,  is  the 
largest  amount  that  can  possibly  be  used,  and  this  quantity  is  danger- 
ous because  it  may  rupture  the  intestine  or  cause  ptosis  or  paresis. 
There  is  no  limit.  howe\er,  to  the  quantity  of  fluid  which  may  be  em- 
plo\ed  when  giving  an  irrigation  where  the  solution  is  allowed  to  flow 
into  and  out  of  the  gut  through  a  double  or  return-flow  tube  or  irriga- 
tor. In  this  way  it  can  escape  as  fast  as  it  enters  the  bowel,  and  the 
same  obtains  when  the  fluid  is  permitted  to  continuously  flow  into 
the  bowel  by  way  of  an  artificial  opening  (appendiceal  or  cecal)  above 


IRRIGANTS 


473 


and  out  at  the  anus  through  a  proctoscope  or  pipe  iniroduced  for  the 
purpose. 

This  class  of  i)atients  are  miserable  so  long  as  poiscjnous  toxins 
and  discharges  are  retained,  consequently,  the  irrigation  should  be 
continued  until  they  have  been  dislodged  and  washed  out.  When  this 
is  done  regularly  it  is  rapidly  followed  by  a  marked  improvement  of 
the  patient's  condition.  Once  these  individuals  have  been  suc- 
cessfully irrigated,  they  regain  confidence  and  feel  that  they  are  on 
the  road  to  recovery  because  something  definite  is  being  done  to  heal 
the  bowel,  and  rejoice  when  they 
find  out  that  it  is  no  longer  neces- 
sary for  them  to  continue  bismuth, 
opium,  and  other  drugs. 

Irrigation  is  not  always  success- 
ful because  in  some  instances  the 
local  disease  has  almost  completely 
destroyed  the  mucosa,  stenoses 
are  present,  systemic  involvement 
has  taken  place,  the  patient  is  so 
devitalized  that  healing  is  impos- 
sible, or  because  the  flushings  have 


Davidson's  syringe. 


Fig.  ii6. — Hydrialic  electrode. 


been  improperly  conducted.  When  the  lluid  reaches  only  one  extrem- 
ity of  the  gut,  or  is  permitted  to  regularly  run  over  the  same  side  of  the 
bowel,  a  cure  cannot  be  affected  because  some  of  the  lesions  are  not 
reached.  From  this  it  may  be  inferred  that  the  solution  must  be  made 
to  pass  from  one  end  of  the  large  bowel  to  the  other  and  the  position 
of  the  patient  frequently  changed,  so  that  the  solution  comes  in  contact 
witli  e\-er\-  side  of  the  entire  length  of  the  diseased  intestine. 

Irrigants. — Water,  normal  saline,  and  medicated  solutions  and 
oils  in  (;ne  iorm  or  another  have  been  successfully  employed  in  the 
treatment  of  intestinal  lesions  inducinti  diarrhea.      Ice-water  irriga- 


474  INTESTINAL    IRRIGATION    (eNTEROCLYSIS) 

tions  have  been  recommended  by  Tuttle  in  entamebic  colitis  (dysen- 
tenO.  but  they  have  been  discarded  by  the  author  because  the  sudden 
injection  of  water  at  a  low  temperature  is  always  uncomfortable,  fre- 
quently induces  intense  pain  or  enterospasm,  and  does  not  produce  as 
good  results  as  some  of  the  other  remedies  to  be  recommended.  If 
one  were  to  remove  entamebae  and  keep  them  in  ice-water  they  would 
die,  but  the  author  doubts  if  they  do  in  the  colon  (under  this  treat- 
ment), because  here  the  ice- water  quickly  becomes  warmer  and  is  no 
longer  fatal,  though  it  may  temporarily  retard  their  activity.  Equally 
good  results  haxe  been  obtained  by  flushing  the  bowel  with  hot  water 
(ioo°  to  iio°  F.).  and  the  patient  greatly  prefers  hot-  to  cold-water 
irrigation  because  the  heat  relieves  pain,  cramps,  and  soreness, 
and  the  water  is  longer  retained  in  the  intestine  to  be  absorbed, 
improve  the  circulation,  and  cause  the  emunctories  to  become  more 
active.  The  author  does  not  attribute  the  beneficial  effects  noticeable 
following  hot-  or  ice-water  irrigations  to  the  temperature,  which  has 
comparatively  little  bactericidal  power  once  the  fluid  reaches  the  gut, 
nor  does  he  believe  that  there  has  yet  been  suggested  a  specific  remedy 
which  can  be  relied  upon  to  kill  entamebae  or  other  micro-organisms 
responsible  for  infectious  colitis.  He  attributes  the  beneficent  action 
of  the  irrigation  to  the  mechanical  action  of  the  fluid,  which,  while 
being  driven  through  the  bowel,  neutralizes  and  washes  out  retained 
toxins,  cleanses  the  inflamed  and  ulcerated  mucosa  of  foul  discharges, 
debris,  irritating  feces,  and  relieves  discomfort,  distention,  pain,  and 
cramps. 

Improvement  invariably  follows  irrigation  of  the  bowel  with  water, 
medicated  solutions,  or  oil,  but  the  good  results  do  not  depend  so 
much  upon  their  temperature  or  the  nature  or  strength  of  the  medica- 
ment as  they  do  upon  the  amount  and  frequency  with  which  the  fluid 
is  used.  No  doubt  antiseptic,  stimulating,  deodorant,  and  soothing 
medicaments  are  of  value  in  the  treatment  of  inflammatory,  ulcera- 
tive, and  obstructive  lesions  of  the  bowel  when  employed  in  conjunc- 
tion with  copious  irrigations,  but  too  much  reliance  should  not  be 
placed  solely  upon  them. 

The  author  will  now  enumerate  and  discuss  the  most  useful  medical 
agents  that  have  been  employed  in  the  irrigating  treatment  of  diarrheal, 
catarrhal,  and  parasitic  diseases  of  the  intestine. 

Quinin  (bisulphate),  i  :  looo  or  1500,  has  been  largely  used  in  the 
treatment  of  entamebic  and  bacillary  colitis  (dysentery- ),  but  in  the 
author's  practice  it  has  not  shown  any  specific  action  nor  given  better 
results  than  the  remedies  mentioned  below.  He  will  not  particularize 
further  because  he  has  found  that  solutions  which  heal  the  inflamed 
or  ulcerated  mucosa  in  one  form  of  colitis  causing  diarrhea  will 
prove  effective  in  another,  irrespective  of  the  cause  or  stage  of  the 
disease. 

Naturally,  the  strength  of  the  contained  medicament  must  neces- 
sarily be  changed  to  meet  indications  in  the  individual  case  because 
they  are  best  used  ver\-  mild  when  the  inflammation  is  slight,  stronger 


IRRKiAXTS 


475 


when  it  is  more  marked  and  there  are  erosions  and  superficial  ulcers, 
and  quite  strong  when  the  lesions  are  large,  numerous,  and  accom- 
panied by  a  profuse  discharge  of  pus,  blood,  and  mucus. 

In  the  average  case  of  ulcerative  colitis  causing  diarrhea  the 
following  solutions  give  very  satisfactory  results: 

In  mild  cases  of  recent  origin  daily  irrigation  with  a  hot  normal 
saline  solution,  camomile,  flaxseed,  or  oak-bark  tea,  pinus  canadensis 
or  hydrastis  (i  per  cent.j,  borolyptol,  potassium  permanganate,  glyco- 
thymolin  or  listerin  (3  per  cent.),  salicylic  acid,  alum,  zinc  sulphate, 


Fig.   117. — Fountain  syringe  with  return-flow  irrigating  attachment. 


copper  sulphate  or  silver  nitrate  (i  per  cent.),  boric  acid  or  Carlsbad 
salt  (2  per  cent.),  or  thymol  (i  :  2000),  will  refresh  the  patient  and 
improve  his  condition. 

When  there  has  been  an  acute  colitis  which  has  subsided  or  there 
are  evident  erosions  and  fair-sized  ulcers  in  the  intestine  which  excite 
peristalsis  and  increase  the  evacuations,  it  is  well  to  employ  the  above 
remedies  a  little  stronger  or  use  the  following  irrigants,  viz.,  ichthyol, 
balsam  of  Peru,  2  to  5  per  cent.;  salicylate  of  soda,  3  to  5  per  cent.; 
or  boric  acid,  5  to  10  per  cent. ;  silver  nitrate,  10  gr.  to  Oij  (0.60-1000.0); 


476  INTESTINAL    IRRIGATION    (eNTEROCLYSIS) 

protargol  or  arg\rol.  2  to  5  per  cent.;  salicylic  acid  or  tannic  acid,  i 
per  cent.,  or  the  following  combination  of  krameria  and  soda,  viz.: 

I^     FluidcKt.  krameriae 5iv  (120.0); 

Sodii  biboratis 5ij  (8.0). — M. 

Sig. — Tablespoonful  to  the  quart  and  irrigate  dailj-  or  three  times  weekl}'.     (Ganl.) 

Originally  krameria  and  water  were  used,  but  the  drug  threw  down 
a  hea\y  precipitate  which  proved  ver\"  irritating,  and  it  was  found  that 
with  the  addition  of  soda  it  formed  a  perfectly  clear,  non-irritating, 
blood-colored  solution.  The  author  uses  this  formula  more  than  any 
other  in  the  treatment  of  the  intestine  when  irritated,  inflamed,  or 
ulcerated,  because  it  is  soothing,  ven,'  healing,  and  never  produces 
toxic  manifestations. 

When  the  mo^'ements  are  frequent  as  a  result  of  severe  chronic 
intestinal  catarrh,  much  can  be  done  to  relieve  and  cure  the  patient 
by  the  injection  of  the  following  combination,  which  is  recommended 
by  Cohnheim: 

I^     Starch oss  (15.0); 

Tannic  acid 5 j  (40) ; 

Water Oij  (looo.o). — M. 

Sig. — Inject. 

In  aggravated  cases  of  diarrhea  consequent  upon  ulcerative  colitis 
of  whatever  kind,  when  the  patient  has  an^-^vhere  from  ten  to  thirty' 
evacuations  daily,  there  is  an  abundance  of  pus,  mucus,  more  or  less 
bleeding,  and  he  suffers  intensely  from  exhaustion  and  auto-intoxi- 
cation, more  radical  measures  are  required.  Under  such  circum- 
stances the  bowel  is  irrigated  with  a  solution  of  silver  nitrate,  gr. 
XXX  to  Oij  (2.0-1000.0),  protargol,  or  arg\Tol  (5  to  10  per  cent.), 
after  which  it  is  flushed  shortly  with  a  normal  saline  solution  to  wash 
out  any  excess  of  silver.  The  former  preparation  is  preferable  be- 
cause it  is  always  eft'ective  and  is  much  less  expensive.  The  author 
employs  the  silver  solution  in  the  above  strength  ever\'  other  day  for 
the  first  week,  and  as  improvement  follows  reduces  the  drug  weekly 
until  only  5  gr.  to  the  quart  fo. 30-1000.0)  are  used,  during  which  time 
on  alternate  days  the  bowel  is  irrigated  with  the  krameria  or  other 
solution.  Usually  by  this  time  marked  improvement  is  noticeable  in 
the  patient's  condition  by  his  improved  appetite,  gain  in  weight,  clear 
complexion,  the  number  of  stools  are  greatly  diminished,  the  discharge 
is  less,  all  of  which  indications  point  to  the  rapid  healing  of  the  ulcers 
and  non-absorption  of  toxins. 

In  very  bad  cases,  next  to  silver  irrigations,  the  author  has  ob- 
tained the  best  results  from  the  employment  of  from  5  to  10  per  cent, 
solutions  of  ichthyol  or  the  balsam  of  Peru,  or  copper  or  zinc  sulphate 
(i  to  2  per  cent.),  but  prefers  the  former  because  the  latter  induce  more 
pain  and  may  cause  toxic  symptoms.  Irrigation  with  a  full  strength 
boric  acid  solution  is  ver\-  ser^-iceable  in  many  cases,  particularly  when 
the  patient  is  on  the  road  to  recover\-,  but  it  is  necessary  to  watch  its 


OILS    AND    EMULSIONS 


477 


action,  because  in  two  of  the  author's  cases  typic  poisoning  occurred, 
necessitating  its  discontinuance. 

Mild  or  soothing  solutions  should  be  substituted  for  strong  ones 
just  as  soon  as  possible,  because  when  long  continued  the  latter  some- 
times irritate  the  mucosa  and  aggravate  instead  of  improving  the  pa- 
tient's general  condition. 

When  the  exacuations  are  extrenieU'  offensive  and  a  deodorant  is 
indicated,  and  of  this  class  of  remedies  none  gives  better  results  than  a 
5  per  cent,  ichthx-ol  or  i  per  cent,  potassium  permanganate  solution, 


Fig.  iiS. — .-Vulhor's  anal  (a.sccndingj  douche. 

injected  two  or  three  times  daily,  although  the  pero.xid  of  hydrogen 
(25  to  50  per  cent.),  acetotartrate  of  aluminum,  i  to  2  per  cent.,  have 
pro\ed  good  disinfectants  in  some  instances. 

Oils  and  emulsions  alone,  or  when  used  in  conjunction  with  one  of 
the  above  solutions  on  alternate  days,  are  a  great  aid  in  ihv  treatment 
of  nearly  all  inflammatory  and  ulcerative  lesions  of  the  intestine  (par- 
ticularly those  of  the  colon  and  rectum),  because  they  are  soothing, 
healing,  afford  a  certain  amount  of  nutriment,  and  favor  absorption 
within  the  large  bowel  thrcnigli  their  tendency  to  quiet  peristalsis  and 
prevent  the  frequent  evacuations.     The  efficacy  of  the  oil  is  greatly 


478 


INTESTINAL    IRRIGATION    (eXTEROCLYSIS) 


enhanced  by  using  it  warm  (90°  to  110°  F.)  to  arrest  enterospasm  and 
intestinal  muscular  rigidity,  lessen  pain,  and  by  the  addition  of  anti- 
septics, styptics,  or  sedatives,  alone  or  combined  with  stimulating 
remedies,  to  favor  healing  of  the  diseased  gut,  diminish  putrefaction, 
and  minimize  the  patient's  discomfort. 

Oils,  named  in  the  order  in  which  their  usefulness  has  been  proved 
by  the  author,  are  crude  petroleum,  olive,  sweet,  almond,  and  cotton- 
seed, liquid  vaselin  and  paraffin,  neutralol,  and  others  of  the  so-called 
mineral  oil  group,  and  kerosene.  Ordinary  oil  is  used  in  much  larger 
quantities  in   the  treatment  of  diarrhea   than   constipation,  because 


Fig.  119. — Funnel  and  tube, 
useful  when  administering  oil 
and  thick  enemata. 


Fig.  120. — Enema  tubes:  A,  Ordinary  colon- 
tube  with  opening  in  the  end;  B,  Murray's  double- 
flow  tube;  C,  pipe  with  eye  in  the  side;  D,  hard- 
rubber  dilating  irrigator. 


here  it  must  be  made  to  reach  the  entire  surface  of  the  inflamed  and 
ulcerated  gut,  while  in  the  latter  it  is  usually  injected  but  a  short 
distance  within  the  bowel  to  soften  and  lubricate  the  feces,  that  they 
may  be  easily  expelled. 

In  the  treatment  of  intestinal  lesions,  oil,  like  irrigating  solutions, 
may  be  introduced  either  from  below  (by  way  of  the  anus)  or  through 
an  artificially  made  opening  at  the  head  of  the  colon  or  appendix. 
A  smaller  amount  of  oil,  however,  is  required,  because  the  irrigating 
fluid  is  permitted  to  flow  in  and  out  at  the  same  time  or  be  expelled 
shortly  after  its  introduction,  while  only  a  sufficient  amount  of  the 


OILS    AND    EMULSIONS 


479 


oil  is  introduced  to  be  retained  and  form  an  oily  or  protective  coating 
to  the  sensitive  bowel.  Warm  oil,  because  of  its  soothing  effect,  is 
retained  very  much  longer  than  cold,  which  is  often  quickly  expelled 
because  it  causes  the  bowel  to  contract.  When  it  is  injected  into  the 
colon  or  sigmoid  flexure  warm  it  is  usually  retained  over  night  or  for 
two  or  three  days,  but  when,  if  it  is  intentionally  or  accidentally  intro- 
duced into  the  rectum  only,  expulsion  takes  place  quickly,  the  expe- 
rienced physician  knows  by  this  sign  whether  or  not  the  oil  has 
been  deposited  in  the  portion  of  bowel  for  which  it  was  intended. 

Oil,  according  to  indications,  may  be  introduced  in  amounts  \ary- 
ing  from  a  few  ounces  to  2  quarts  or  more,  Haynes  having  repeatedly 
used  as  much  as  a  gallon  of  kerosene  at  one  treatment,  but  the  using 
of  so  large  a  quantity  is  undesirable,  because  all  parts  of  the  intes- 
tine can  be  reached  by  a  smaller  amount  and  with  less  discomfort  to 
the  patient. 


Fig.  121. — Jamison's  seat  syringe. 

The  above  oil  preparations  when  continuously  employed  do  not 
produce  any  unpleasant  manifestations,  except  that  sometimes  the 
patient  can  taste  them  and  they  are  noticeable  upon  his  breath  or 
dribble  through  the  anus. 

In  the  majority  of  instances  better  results  are  obtained  when  each 
quart  of  the  oil  contains  5ss  to  ij  (15.0-60.0)  of  bismuth  subnitrate 
or  carbonate,  because  these  chemicals  have  antiseptic  properties,  are 
sedative,  and  form  a  coating  which  protects  the  raw  surfaces  of  the 
gut,  allays  intestinal  irritability,  and  lessens  peristaltic  activity. 
Aristol,  bismuth  subgallate,  beta-naphthol,  salol,  creosote,  and  iodo- 
form in  smaller  amounts  are  also  serviceable  for  the  same  purposes. 

The  author  knows  of  no  remedy  which  is  more  soothing  and  healing 
or  gives  better  results  in  the  treatment  of  diarrhea  incident  to  an  in- 
flamed and  ulcerated  colon  or  rectum  than  the  following  emulsion, 
viz.: 

I^     Pulv.  opii gr.  ij  to  V  (0.13-0.3); 

Iodoform 5ss  to  j  (2.0-4.0); 

Bismuth  subnitrate oij  (60.0) ; 

Olive  oil ...   Oij  (looo.o). — M. 

Ft.  emulsion. 
Sif . — Warm  and  inject  all  or  any  part,  according  to  indications. 


48o 


INTESTINAL    IRRICIATION    (eNTEROCLYSIS) 


In  this  class  of  cases,  when  the  stools  arc  irritating  and  foul  smell- 
ing, the  addition  of  ichthyol  or  l)alsam  of  Peru  (5  per  cent.)  to  the  oil 
combination  deodorizes  the  mo\ements  and  arrests  burning  pain  and 
tenesmus  in  the  rectum. 


Fig.  122. — Metliiid   of  t'lllini;  the  loloii  with  oil  or  s()lutioii>  1)>   nuan>  ot  (lant's  funnel 
pitcher  and  funnel  proctoscope,  while  the  patient  is  in  the  in\ertetl  j)osture. 

Gelatin. — When  oil  proxes  objectionable  in  any  way,  gelatin, 
which  is  non-irritating,  should  be  substituted  for  it,  because  bismuth 
remains  suspended  in  it  for  a  considerable  time. 

Technic  of  Bowel  Irrigation. — The  technic  of  enteroclysis  is  not 
understood  and  is  more  difficult  to  carry  out  than  is  generally  supposed 
by  physicians  and  nurses.  The  essential  features  in  the  procedure  are 
the  placing  of  the  patient  in  the  projier  posture  and  properly  arranging 


TECHNIC    OF    BOWEL    IRRKIATION 


481 


the  tube  or  apparatus  by  means  of  wliich  the  irrigation  is  to  be  con- 
ducted into  the  bowel. 

The  following,  named  in  the  order  of  their  importance,  are  the 
positions  (Figs.  122,  123)  best  suited  for  enteroclysis  and  colonic  irri- 
gation when  they  are  to  be  administered  in  the  office — inverted,  knee- 
chest,  dorsal,  right  and  left  Sims',  and  sitting. 

When  the  bowel  is  irrigated  by  the  author,  his  assistant,  or  nurse, 
the  knee-chest  or  inverted  postures  are  preferable  because  of  the 
time  saved,  owing  to  the  fact  that  the  small  intestine  and  pelvic  organs 
fall  away  from  the  rectimi  and 
permit  a  rapid  inflow  of  tlie 
fluid.  In  the  former  the  in- 
let to  the  sigmoid  flexure  is 
quickly  exposed  by  means  of 
a'proctoscope  of  suitable  size, 
and  the  tube  attached  to  the 
container  is  then  introduced 
into  the  sigmoid  flexure  and 
the  desired  amount  of  fluid  or 
oil  is  permitted  to  flow  into 
the  bowel.  When  the  patient 
is  placed  in  an  inverted  pos- 
ture, an  examining  or  the 
author's  funnel  proctoscope 
(Fig.  122)  is  introduced  and 
the  fluid  or  oil  is  poured  di- 
rectly into  the  colon,  using  the 
author's  pitcher  which  has  an 
attached  funnel  or  procto- 
scope (Fig.  124).  Usually 
from  I  to  2  quarts  can  be 
introduced  within  five  min- 
utes, though  sometimes  gas 
or  air  prevents  rapid  entrance 
of  the  irrigant,  a  difficulty 
easily  overcome  by  changing 
the  position  of  the  instrument 
or  withdrawing  and  reinsert- 
ing it.  When  desirable,  the  proctoscopic  end  of  the  author's  pitcher 
can  be  introduced  into  the  rectum,  and  the  fluid  or  oil  passes  into  the 
upper  bowel  as  soon  as  the  obturator  is  removed  (F"ig.  122).  This 
position  is  cumbersome  and  objectionable  to  women,  but  there  can 
be  no  doubt  of  its  effecti\-eness,  and  once  the  patient  has  had  the  irri- 
gation in  this  position  it  is  preferred  to  others.  In  this  and  the  knee- 
chest  posture,  when  the  patient  complains  of  the  proctoscope,  a  smaller 
one  should  be  substituted,  or,  if  necessary,  it  should  be  discarded  and 
a  rubber  tube  connected  with  a  funnel  (jr  heavy  piston-syringe  may 
be  used  instead  (Fig.  114). 
31 


Fi£ 


>,^. — Method  of  irrij^atinj^  the  colon  and 
rectum  with  a  two-way  irris'ator. 


482 


INTESTINAL    IRRIGATION    (ENTEROCLYSIS) 


When  patients  irrigate  themselves  the  dorsal,  Sims',  or  sitting  pos- 
tures are  recommended,  and  they  are  told  to  use  the  one  which  gives 
the  best  results,  but  of  these  the  first  two  are  the  most  reliable.  Bet- 
ter results  are  obtained  when  the  hips  are  elevated  and  the  patient's 
position  is  changed  from  time  to  time  if  the  water  does  not  readily 
enter.  Water  or  other  fluids  can  be  introduced  into  the  rectum  and 
all  parts  of  the  colon  quickly  and  with  little  discomfort  to  the  patient 
by  means  of  a  suitable  syringe  if  the  person  giving  the  injection  will 
use  a  little  patience.  The  solution  can  be  made  to  move  from  one  part 
of  the  bowel  to  another  by  having  the  patient  turn  from  left  to  right, 
or  vice  versa,  as  occasion  demands.  Because  of  the  tendency  of  the 
abdominal  or  pelvic  organs  to  drop  downward  and  obstruct  the  bowel. 


F 


Fig. 


1 24. — Gant's  combined  funnel  proctoscope  and  pitcher  emploj-ed  for  pouring  oil  or 
solutions  directly  into  the  colon  with  the  patient  in  an  inverted  pasture. 


the  sitting  posture  is  not  advisable  for  injections  except  when  it  is 
desirable  to  secure  an  immediate  evacuation  by  throwing  in  a  small 
quantit}.-  of  fluid.  If  the  patient  is  a  child,  enemata  can  be  most 
effectively  given  with  the  child  lying  upon  its  abdomen  and  across  the 
lap  of  the  mother. 

The  quickest  and  most  satisfactory-  way  of  filling  the  colon  with 
oil  or  water  is  to  place  the  patient  in  the  inverted  posture  and  pour 
it  in.  using  the  author's  funnel-shaped  proctoscope  and  pitcher  (Fig. 
124),  but  when  the  patient  objects  to  the  posture  some  other  plan 
must  be  adopted. 

The  apparatus  used  for  the  purpose  of  injecting  irrigating  solutions 
and  oils  into  the  bowel  may  be  simple  or  elaborate,  but  the  former,  as 
a  rule,  are  more  durable,  effective,  and  less  expensive. 


TECHNIC    OF    BOWEL    IRRKIATION  483 

The  essential  parts  of  an\'  irrip,atin;4  (nil fit  are  the  container  (Fig. 
112)  and  the  tube  (Fig.  125,  A)  througli  which  the  lluid  (lows  into  the 
bowel.  The  following  paraphernalia  are  most  generally  used  for  giv- 
ing enteroclysis  and  high  and  low  enemata — viz.,  the  fountain,  David- 
son, and  piston  syringes  (Figs,  in,  115,  117),  and  different  kinds  of 
special  apparatus.  Of  these,  the  first  two  are  the  most  satisfactory 
where  the  medium  to  be  introduced  is  a  thin  fluid,  while  the  two 
last  are  ])referable  when  force  is  required  to  inject  oil  or  any  thick 
solution  into  the  colon. 

The  tubes  through  which  the  water  is  carried  into  the  bowel  are 
variable  in  size,  shape,  and  length,  and  may  be  made  of  metal  and  soft 
or  hard  rubber,  but  should  in\ariably  be  smooth  and  of  such  size  and 
shape  as  not  to  cause  irritation  or  pain.  Irrigating  tubes  should  vary 
in  size  from  |  to  |  inch  (0.93-1.25  cm.)  in  diameter  for  ordinary  pur- 
poses, and  from  f  to  i  inch  (1.87-2.50  cm.)  when  employed  to  quickly 
soften  and  wash  out  discharges  and  fecal  masses  from  the  rectum 
or  sigmoid.  Irrigating  pipes  when  short,  2  to  6  inches  (5-15  cm.), 
are  called  rectal,  and  when  long,  18  to  36  inches  (45-90  cm.),  colon- 
tubes.  Soft-rubber  colon-tubes  are  employed  for  giving  high  colonic 
irrigation  and  enemata,  and  the  short,  soft,  or  hard  pipes  for  washing 
out  the  rectum.  The  long  tube  is  convenient,  but  not  necessary 
for  high  irrigation,  because  by  elevating  the  patient's  hips  and 
having  him  change  his  position  the  solution  injected  through  a  short 
tube  can  be  made  to  enter  all  parts  of  the  bowel,  colon,  and  some- 
times lower  ileum  (Fig.  125).  Unless  contra-indicated,  the  fluid  used 
for  high  and  low  enemata  should  be  warm,  and  permitted  to  flow  into 
the  gut  slowly,  to  avoid  the  discomfort  and  pain  which  ensue  when  it 
is  cold  or  the  intestine  is  quickly  distended. 

There  are  two  types  of  irrigators — viz.,  tubes  having  an  inflow 
(Fig.  120,  A,  C,  D),  and  those  having  both  an  inflow  and  an  outflow 
(Fig.  120,  B).  The  single-bore  pipe  is  used  when  the  fluid  is  to  be 
injected  and  allowed  to  remain,  and  the  return-flow  irrigator  when  it 
is  desirable  to  medicate  the  bowel,  wash  out  poisons  or  scybala,  and 
keep  the  irrigating  solution  at  even  temperature.  The  double-flow 
tube  provides  the  mechanic,  thermic,  and  solvent  action  of  the  fluid 
without  causing  the  discomfort  and  pain  from  distention  incident  to 
the  introduction  of  considerable  fluid  into  the  bowel  which  is  allowed 
to  remain  until  it  comes  away  spontaneously.  On  the  other  hand, 
when  it  is  desirable  to  have  water  or  a  medicated  solution  retained 
the  single-bore  pipe  is  preferable.  The  author  prefers  the  opening  to 
be  in  the  end  (Fig.  120,  A)  rather  than  in  the  side  (Fig.  120,  C)  of  the 
tube  or  irrigator,  so  that  the  water  may  run  directly  through  it  and 
dislodge  feces,  a  fold  of  mucosa,  or  a  rectal  vaKe  which  interferes  with 
its  passage. 

Irrigating  pipes  of  all  kinds  should  be  made  in  such  a  wa\"  and  of 
such  material  as  to  permit  their  frequent  sterilization. 

After  experimenting  for  a  number  of  years  with  irrigating  para- 
phernalia the  author  is  convinced  that  the  apparatus  described  below 


484 


INTESTINAL    IRRIGATION    (eNTEROCLYSIS) 


is  the  most  satisfactor>-  for  office  and  hospital  use  because  it  is  effec- 
tive, holds  enough  solution  for  several  irrigations,  and  the  stench 
from  evacuated  discharges  and  feces  is  prc\-ented  from  escaping. 


Fig.  125.— Apparatus  used  in  author's  office  and  sanitarium  for  rcLiuLuluiUL  irrigation. 

The  apparatus  (Fig.  125).  which  explains  itself,  is  employed  in  the 
following  manner:  Introduce  the  colon-tube  (.4)  into  the  bowel    and 


TECHNIC    OF    BOWEL    IRRKIATION 


4S5 


turn  stop-cock  (B)  so  thai  theHuid  enters  the  intestine  under  pressure 
regulated  by  the  amount  of  air  which  is  forced  into  the  bottle  (C)  by 
the  rubber  hand-bulb  (D).  B\-  reversing  stop-cock  (B)  the  flow  from 
the  bottle  (C)  is  arrested,  and  the  irrigating  fluid  returns  from  the  bowel 
and  passes  downward  into  bottle  (E).  The  contents  of  the  bottle  (£) 
can  be  satisfactorily  deodorized  by  placing  a  small  amount  of  potassium 
permanganate,  charcoal,  or  ichthyol  in  the  bottle  prior  to  the  irriga- 
tion. 


Fig.  126. — Gant's  double-flow  irrigating  proctoscope. 


A  low  or  a  high  irrigation  or  la\age  can  be  administered  by  altering 
the  pressure,  and  the  fluid  be  retained  for  as  long  or  as  short  a  time  as 
may  be  desired.  This  plan  of  injecting  water  into  all  parts  of  the  large 
bowel  is  simple,  clean,  and  etTective.  Another  satisfactory  procedure 
is  to  connect  one  end  of  the  long  colon-pipe  with  a  funnel  (Fig.  119), 
insert  the  tube  to  the  desired  height,  and  then  pour  the  fluid  or  oil  into 
the  funnel,  from  which  it  will  soon  find  its  way  into  the  colon  when 


486  IXTHSTINAL    IRRIGATION'    (eNTKROCLYSIS) 

raised  above  the  patient,  while  upon  his  side,  back,  knees,  or  in  the 
inverted  posture.  Still  another  effective  way  of  introducing  oil  is  to 
connect  the  colon-tube  with  a  strong  metal  syringe  (Fig.  114),  which 
forces  it  into  the  bowel. 

Oil  should  not  be  employed  in  the  fountain  syringe  because  of  its 
tendency  to  stick  in  the  tube  and  rot  the  rubber. 

It  is  easy  to  insert  a  rectal  tube,  but  the  introduction  of  a  long  or 
colonic  tube  is  always  difficult  or  impossible  (Fig.  127). 

The  author's  technic  of  passing  a  colon-tube  is  as  follows:  With  the 
patient  preferably  in  the  Sims,  inverted,  or  knee-chest  postures  the 
pipe,  properly  warmed  and  lubricated  with  vaselin  or  other  stiff'  lubri- 
cant, is  grasped  by  the  fingers  of  the  right  hand  about  2  inches  from 
the  end,  and  gradually  inserted  into  the  rectum  with  a  side-to-side  or 
boring  motion,  while  the  buttocks  are  separated  with  the  fingers  of 
the  left  hand.  First  it  is  directed  upward  and  forward  until  the  anal 
canal  and  the  levator  ani  muscles  have  been  passed,  and  thence 
upward  and  backward,  above  the  upper  rectal  valve,  into  the  sigmoid 
flexure.  After  the  tube  reaches  O'Beirne's  sphincter  its  direction  cannot 
be  perfectly  controlled,  and  it  must  be  permitted  to  find  its  way  along 
the  bowel. 

The  principal  anatomic  obstructions  to  introduction  of  the  pipe, 
named  in  their  order  from  below,  are — viz.,  the  sphincter  muscle,  folds 
of  mucosa,  Houston's  valves,  O'Beirne's  sphincter,  and  the  angulated 
sigmoid  flexure.  When  the  sphincter  is  irritable  and  contracts  the 
tube  should  be  continuously  pressed  against  the  muscle  until  it  re- 
laxes and  permits  it  to  enter  the  rectum.  By  allowing  the  fluid  to 
flow  through  the  tube  as  it  passes  upward  the  pipe  is  stiffened,  and 
this,  with  the  water  flowing  in,  keeps  displacing  the  valves,  folds  of 
mucosa,  or  scybala  which  may  be  in  the  way.  When  O'Beirne's 
sphincter  spasmodically  contracts  and  blocks  the  tube  the  difficulty 
is  overcome  by  hot  fomentations  and  injection  of  warm  water  or  oil, 
which  soothe  and  cause  the  intestinal  musculature  to  relax. 

Force  should  never  be  employed  when  introducing  a  colon-tube 
or  stiff  bougies,  because  the  bowel  ma>'  be  ruptured;  and,  for  the  same 
reason,  large  amounts  of  fluid  should  not  be  employed  at  a  single  sitting 
except  when  it  is  permitted  to  escape  through  a  return-flow  tube. 

When  it  is  impossible  to  insert  the  long  colon-tube  in  the  abov^e 
manner  after  introduction  of  the  sigmoidoscope  (Fig.  127),  it  should 
be  introduced  into  the  lower  sigmoid,  from  which  the  water  can  be 
made  to  enter  all  parts  of  the  colon  by  elevating  the  hips  of  the 
patient  and  turning  him  from  his  left  to  his  right  side,  irrespective 
of  whether  the  pipe  passes  entirely  through  the  sigmoid  flexure  or  not. 
The  accompanying  .r-ray  photograph  illustrates  the  futility  of  attempt- 
ing to  pass  a  soft  tube  well  into  the  colon,  and  it  is  doubtful  it  this  is 
ever  accomplished  (F'ig.  127). 

Passage  of  the  colon-tube  causes  but  little  discomfort  except 
when  it  curls  up  in  the  rectum  or  sigmoid  flexure,  and  if  it  does,  or  the 
fluid  or  oil  does  not  flow,  it  should  be  withdrawn  and    reintroduced 


TECHNIC    OF    BOWEL    IRRIGATION 


487 


until  the  irrlgant  passes  freely  into  {he  bowel.  At  times  it  is  difficult 
to  determine  whether  or  not  the  tube  has  reached  the  desired  height, 
but  by  using  a  iitiU'  ingenuity  one  can  usually  decide  the  point. 

When  doubled  up  (b'ig.  127)  it  causes  pain  in  the  upper  rectum  and 
pelvis,  tenesmus,  and  a  tendency  on  the  part  of  the  bowel  to  expel  it; 
the  solution  will  not  How,  and  wlu'U  slightly  wilhchawn  the  tube 
comes  out  with  a  (juiver  or  jerk,  and  can  be  felt  b\  abdominal  palpa- 
tion doubled  up  when  the  finger  is  inserted  into  the  rectum  or  vagina, 
but  when  the  pipe  has  reached  the  sigmoid  and  is  uncjbstrucled  the 
fluid  runs  freely,  and  when  the 
solution  or  oil  is  hot  or  cold  the 
patient  at  once  feels  it  entering 
the  colon.  I'luid  in  the  rectum 
is  promjjtly  evacuated,  but  when 
deposited  in  the  colon  it  remains 
several  minutes,  liours,  or  over 
night. 

Except  when  destined  for  sju'- 
cific  purposes  very  cold  solutions 
(50°  to  60°  F.)  should  not  be  used 
for  irrigating  purposes,  becaus,' 
they  incite  a  powerful  contraction 
of  the  intestinal  musculature  (en- 
terospasm)  and  are  immediately 
expelled  or  unduly  retained.  On 
the  contrary,  warm  or  hot  (100° 
to  110°  F.)  irrigants  are  desirable 
because  they  soothe  the  bowel 
and  relieve  pain  and  cramps. 

When  it  is  desirable  to  have 
the  irrigations  retained  for  a  greater  or  less  time  the  Strous  irrigator 
is  employed,  or  a  large-sized  Young's  self-retaining  anal  dilator  (Fig. 
120,  D)  is  inserted  to  prevent  leakage  after  a  sut^cient  (luantity  of 
the  fluid  has  been  introduced. 

Electrification  of  the  solution  is  occasionally  helpful,  in  which  case 
a  hydriatic  tube  electrode  (Fig.  116)  is  serviceable. 

Following  appendicostomy  and  cecostomy,  through-and-through 
irrigation  maybe  carried  out  by  means  of  a  small  catheter,  metal,  glass, 
or  hard-rubber  irrigator,  attached  to  the  connecting  rubber  tube  of 
the  container  by  introducing  it  into  the  artificial  ()i)ening  and  per- 
mitting the  solution  to  run  into  and  out  of  the  bowel  through  a 
proctoscope  inserted  for  the  purpose,  or  it  may  be  retained  and  ex- 
pelled later,  according  to  indications,  after  the  colon  has  become  filled. 
When  the  author's  appendiceal  (Fig.  152)  and  enterocolonic  irrigators 
have  been  introduced  at  the  time  of  operation  the\'  can  be  used  and  the 
irrigations  started  at  once  (Figs.  155,  156). 

When  catheters  are  left  in  situ  (Fig.  no)  they  become  soiled  and 
irritable  and  should  be  changed  from  time  to  time. 


127. — Radiogram  showing  how  for- 
cible introduction  of  the  colon-tube  causes 
it  to  coil  upon  itself  many  times,  which  pre- 
vents the  solution  from  passing  into  the 
colon  above. 


CHAPTER  XLII 
OBSTRUCTIVE    MECHANIC,   SURGICAL  >   DIARRHEA 

GENERAL  REMARKS,  ETIOLOGY 

General  Remarks. — Obstructive  represents  a  type  of  diarrhea  where- 
in the  evacuations  are  made  more  frequent  or  Uquid  incident  to  the 
presence  of  fecal  impactions,  foreign  bodies,  or  lesions  in  or  adjacent 
to  the  bowel  which  occlude  it  so  that  solid  matter  is  retained,  while 
the  water\'  constituent  of  the  feces  is  permitted  to  escape  and  be 
evacuated  at  frequent  intervals.  From  what  has  been  said  it  may  be 
inferred  that  this  form  of  loose  movements  represents  one  of  the 
manifestations  of  acute  and  chronic  intestinal  obstruction,  and  that  it 
must  necessarily  complicate  this  affection  in  many  cases. 

If  the  frequency  and  importance  of  diarrhea  as  a  symptom  of 
intestinal  obstruction  and  other  diseases  of  the  intestine  was  understood 
bv  practitioners  in  general,  hundreds  of  lives  would  be  saved  annually, 
because  then  many  lesions  which  now  terminate  fatally  would  be 
diagnosed,  operated  upon,  and  cured. 

In  this  discussion  diarrhea  and  obstipation  (constipation)  naturally 
go  hand  in  hand,  because,  as  a  rule,  patients  afflicted  with  frequent 
evacuations  consequent  upon  obstruction  suft'er,  first,  from  constipa- 
tion; then,  costiveness  alternating  with  loose  movements,  and  finally, 
diarrhea.  Owing  to  this  corelation  between  obstructive  diarrhea  and 
constipation  the  author  has  made  frequent  reference  to  the  text,  statis- 
tics, and  illustrations  contained  in  his  former  work.^ 

Physicians,  owing  to  past  and  present  defective  methods  of  under- 
graduate teaching,  generally  hold  to  the  belief  that  diarrhea  is  nearly 
always  consequent  upon  errors  in  diet,  ner\'ous  phenomena,  digestive 
disturbances,  enteritis,  colitis,  ptomain-poisoning,  affections  of  the 
liver,  pancreas,  and  other  organs.  These  affections  unquestionably 
constitute  the  most  frequent  factors  in  diarrhea,  but  by  no  means  cover 
all  cases,  because  bowel  obstruction  is  responsible  for  loose  movements 
in  many  instances,  though  one  hears  little  about  it  in  our  colleges, 
medical  societies,  text-books,  or  current  literature. 

The  author  for  many  years  has  done  what  he  could  to  point  out 
the  various  types  of  diarrhea,  advise  against  their  medicinal  treatment 
in  so  far  as  practicable,  and  emphasize  the  good  results  obtainable 
in  this  class  of  cases  by  direct  treatment  of  the  bowel  and  surgical 
operations. 

His  interest  in  this  subject  has  led  his  medical  friends  and  former 
patients  to  refer  to  him  many  sufferers  who  sought  relief  from  diarrhea. 

'  Gant,  Constipation  and  Intestinal  Obstruction  (Obstipation),  igio.  W.  B.  Saun- 
ders Co. 


GENERAL    REMARKS  489 

The  author  has  treated  many  hunch-eds  of  iiulixichials  for  cHarrhea,  and 
his  rather  extensive  private  and  cUnic  statistics  indicate  that  about 
20  per  cent,  were  afflicted  with  some  form  of  oljstruction. 

The  author  operates  frec}uently  for  the  rehef  of  both  obstipation 
and  cHarrhea  due  to  intestinal  blocking,  and  he  probably  sees  a  greater 
percentage  of  individuals  afflicted  with  obstructive  diarrhea  than  the 
internist  or  general  practitioner,  and  his  large  experience  has  con- 
vinced him  that  the  obstructive  form  of  diarrhea  prevails  in  from  15  to 
20  per  cent,  of  ihe  cases,  and  that  the  location  and  character  of  the 
blocking  can  usually  be  determined  when  a  careful  examination  is 
made.  The  obstructive  is  almost  daily  being  mistaken  and  treated 
for  other  types  of  diarrhea,  because,  through  ignorance  or  carelessness, 
the  physician  does  not  arrive  at  a  correct  diagnosis,  and  this  is  sur- 
prising, because,  with  the  aid  of  test-meals,  palpation,  percussion,  bis- 
muth injections,  the  fiuoroscope,  ^c-ray  photographs,  inflatable  bag, 
or  sigmoidoscopic  examination,  the  peristaltic  waves  can  be  studied 
and  lesions  blocking  the  bowel  located  with  precision  in  most  instances, 
and  the  cause  of  gastrogenic  and  other  diarrheal  conditions  can  be 
determined  through  examination  of  the  stomach  and  intestinal  con- 
tents, etc. 

Obstructions  located  in  the  esophagus  and  stomach  seldom  induce 
diarrhea,  and  when  they  do,  increased  freciuency  of  the  evacuations 
results  from  digestive  disturbances  or  local  irritation  of  the  nerves  which 
lead  to  reflex  phenomena  and  augmentation  of  peristalsis  and  glandular 
secretion. 

Obstruction  and  consequent  diarrhea  of  the  small  intestine  is  en- 
countered more  frequently  and  increases  in  frequency  from  above 
downward;  but  blocking  responsible  for  diarrhea  is  located  in  the 
colon,  sigmoid  flexure,  or  rectum  in  80  per  cent,  or  more  of  the  cases. 
In  the  author's  experience  the  obstruction  has  been  encountered  most 
often  in  the  rectum,  and  then,  in  order  of  their  frequency,  the  sigmoid, 
splenic  and  hepatic  flexures,  cecum,  and  transverse  colon.  It  was 
observed  in  this  class  of  cases  that  the  ascending  and  descending  colons 
were  rarely  blocked,  and  that  the  lesions,  benign  or  malignant,  causing 
it  were  usually  located  in  the  above-mentioned  or  segments  of  gut 
which  are  most  frequently  subjected  to  trauma.  Splanchnoptosis, 
coloptosis,  adhesions,  kinks,  angulations,  and  invagination  are  the 
chief  etiologic  factors  in  obstruction  involving  the  small  bowel,  cecum, 
ascending,  descending,  and  transverse  colons;  but  malignant  neo- 
plasms are  usually  the  cause  of  occlusion  of  the  sigmoid  flexure  and 
rectum. 

The  author  has  observed  both  mechanic  and  other  types  of  diar- 
rhea very  much  more  frequently  in  men  than  in  women,  and  in  indi- 
viduals between  twenty  and  forty  years  of  age  more  often  than  in 
older  or  younger  persons,  except  cancer  patients,  whose  ages  \-ariefl 
from  forty  to  sixty-five. 

Numerous  types  of  intestinal  obstruction  sooner  or  later  lead  to 
frequent  or  fluid   e\acuations,   some  of  which   constantK-   block   the 


490  OBSTRUCTIVE    (MECHANIC,    SURGICAL)    DIARRHEA 

bowel,  and  the  patient  suffers  all  the  time,  while  others  intermittently  ob- 
struct the  fecal  current,  excite  peristalsis,  or  augment  the  secretions,  and 
diarrhea  is  complained  of  at  shorter  or  longer  intervals  during  the  crises. 

Sometimes  loose  mo\'ements  are  indicated  by  a  single  mechanic 
cause,  but  in  others  obstipation  and  diarrhea  result  from  bowel  block- 
ing at  two  or  more  points,  viz.,  in  multiple  stricture,  angulation, 
or  polypus,  and  when  the  above  or  other  lesion  is  complicated  by 
ptosis,  adhesions,  extra  intestinal  pressure,  tumor,  or  fecal  impactions 
located  in  the  rectum  and  colon. 

Physicians  often  fail  to  relieve  patients  under  the  above  circum- 
stances because  their  examination  is  superficial  and  they  detect  and 
treat  but  one  obstruction  and  leave  the  others  undisturbed.  The 
author  has  several  times  discovered  in  the  same  case  obstructing  lesions 
located  in  the  rectum,  the  sigmoid,  colon,  and  abdomen  that  were 
capable  of  producing  mechanic  diarrhea.  In  patients  where  there  are 
multiple  obstructions  the  diarrhea  is  usually  due  to  pericolic  membranes 
or  adhesions,  the  sequelae  of  appendicitis,  typhlitis,  colitis,  typhoid 
fever,  peritonitis,  or  suppurative  disease  in  the  pelvis  or  abdomen 
which  binds  the  bowel  to  the  parietal  peritoneum,  small  intestine, 
stomach,  diaphragm,  bladder,  tubes,  or  uterus. 

Exceptionally,  lesions  causing  obstructive  diarrhea  can  be  corrected 
by  exercise,  massage,  electricity,  or  vibration,  but  in  the  majority  of 
instances  they  cannot  be  eradicated  except  by  operation,  and  because 
of  this  it  has  been  the  author's  custom  to  classify  diarrhea  as  surgical 
when  it  is  traceable  to  obstructive  or  mechanic  causes. 

It  does  not  follow  that  because  the  disease  or  defect  inducing 
diarrhea  is  dangerous  that  the  operation  necessary  for  its  cure  or  correc- 
tion is  perilous,  for  often  the  lesions  responsible  for  obstinate  cases  are 
easy  to  remedy  and  with  the  least  disturbance  to  the  patient.  As  a 
rule,  operations  performed  for  the  relief  of  obstructive  diarrhea  take 
but  a  few  moments,  are  not  dangerous,  give  flattering  results,  and 
leave  few  sequelae,  irrespective  of  whether  the  block  is  in  the  rectum, 
colon,  or  abdomen.  Naturally,  procedures  like  colonic  resection  and 
excision  or  rectal  extirpation  and  those  complicated  by  abscess  are 
more  serious,  but  they  are  seldom  indicated. 

Obstipation  prevails  when  blocking  is  slight,  there  is  diarrhea 
alternating  with  constipation  when  obstruction  is  marked,  and  per- 
sistent diarrhea  (complicated  by  impaction)  is  present  when  the 
obstruction  is  nearly  complete. 

Etiology. — The  frequent  and  fluid  movements  incident  to  acute 
and  chronic  intestinal  obstruction  may  be  caused  in  several  ways. 
Sometimes  the  occlusion  is  marked  and  only  mushy  or  liquid  feces  can 
get  by  it;  in  others,  where  irritation  causes  the  secretion  of  mucus  in 
large  quantities,  and  in  still  others  the  lesion  stimulates  peristaltic 
activity  which  interferes  with  digestion  and  hurries  the  feces  downward 
to  be  discharged  before  absorption  can  take  place  or  they  have  been 
given  an  opportunity  to  solidify.  Frequently  in  bowel  blocking  (in- 
testinal stasis),  fermentative,  putrefactive,  and  other  intestinal  bac- 


ETIOLOGY  491 

tenia  and  their  toxins  are  active,  and  augment  intestinal  peristalsis, 
glandular  secretion,  and  the  number  of  daily  movements  through 
their  action  upon  the  mucosa,  ner\-es,  or  circulation. 

Another  factor  which  tends  to  aggravate  diarrhea  in  intestinal 
obstruction  is  the  nervous  state  of  the  patient  induced  by  the  thought 
that  he  is  suffering  from  a  dangerous  or  incurable  disease. 

Chronic  obstruction  is  nearly  always  complicated  by  ball-like 
fecal  masses  which  irritate  the  bowel  and  increase  the  movements. 
These  fecal  tumors  usually  lead  to  pressure  necrosis  and  stercoral 
ulcers  and  exposure  of  the  nerve-filaments,  which  become  irritated  and 
excite  peristaltic  activity  and  a  greater  number  of  stools.  When  the 
rectum  is  filled  with  scybala  or  putty-like  masses  fluid  feces  continu- 
ously dribble  past  the  impaction  and  out  at  the  anus.  Xow  and  then 
irritating  gases  collect  above  the  obstruction  and  aggravate  the  diar- 
rhea until  they  have  been  expelled. 

Any  of  the  following  mechanic  or  obstructi\"e  lesions  ma\'  block 
the  bowel  and  cause  diarrhea  alone  or  alternating  with  obstipation — 
viz.:  congenital  deformities;  extra-intestinal  pressure;  strictures;  malig- 
nant and  non-malignant  neoplasms;  foreign  bodies;  intestinal  calculi 
{enteroliths) ;  fecal  impaction  (coprostasis) ;  adhesions  (including  tume- 
factiojis,  pericolic  membranes,  and  peritoneal  and  fibrous  bands);  angu- 
lations, flexures;  diverticula  and  rectocele;  pericolitis  and  perisigmoiditis 
{pericolic  membranes);  sacculation  {rectocolonic) ;  abnormal  or  diseased 
mesentery;  volvulus  and  kinks;  hernia;  invagination,  intussusception, 
rectal  procidentia;  splanchnoptosis  and  enteroptosis;  paralytic  ileus; 
dilatation  of  the  colon  {congenital  and  acquired);  postoperative  sequelce; 
enterospasm;  intestinal  parasites  {worms);  hypertrophy  of  O'Beirnes 
sphincter;  hypertrophy  of  the  rectal  valves;  hypertrophy  of  the  levator  ani; 
hypertrophy  of  the  sphincter  ani;  anterior  deviation  of  the  coccyx;  diseases 
of  the  rectum  and  anus  (hemorrhoids  ?ind  fissures)  which  excite  muscular 
contraction  or  block  the  boivel. 

Congenital  deformities  have  been  encountered  in  all  parts  of  the 
small  and  large  intestine,  but  occur  most  frequently  in  the  colon, 
sigmoid  flexure,  or  rectum.  When  the  gut  is  abnormally  large,  narrow, 
long,  kinked,  displaced,  strictured,  or  occluded  by  membranous  par- 
titions, and  the  deformity  prevents  the  passage  of  solid  feces  and  leads 
to  fecal  impaction,  increased  frequency  and  fluidity  of  the  stools  in- 
variably obtains. 

Malformations  are  commonly  encountered  in  the  rectum  or  at  the 
anus,  and  the  one  or  the  other  is  imperforate,  narrowed,  or  blocked 
by  transverse  bands  which  induce  partial  or  complete  obstruction. 
Diarrhea,  however,  is  most  often  a  sequel  of  operations  performed  for 
the  relief  of  congenital  deformities  of  the  colon,  rectum  (Fig.  128),  or 
anus  which  have  led  to  peri-intestinal  adhesions  or  stenoses. 

Extra-intestinal  pressure  incident  to  abdominal  and  pelvic  tumors 
or  enlargement  and  displacement  of  the  uterus  (Fig.  129),  adnexa, 
prostate,  or  other  organs  occasionally  block  the  bowel  and  interfere 
witli  the  movements. 


492 


OBSTRUCTIVE    (MECHANIC,    SUR(.ICAL)    DIARRHEA 


Foreign  bodies  (intestinal  sand,  calculi,  etc.),  which  traumatize,  irri- 
tate or  obstruct  the  intestine,  usually  induce  obstinate  loose  move- 
ments. 

Fecal  impaction  (coprostasis)  resulting  from  constipation,  chronic 
intestinal  obstruction,  enterospasm,  or  other  cause,  is  frequently  com- 


Fig.   128. — Imperforate  anus,  the  rectum         Fig.  129. — Rectal  obstruction  produced  by 
ending  in  a  blind  pouch.  a  retroverted  uterus. 

plicated  by  diarrhea,  because  the  scybala  or  larger  firm  fecal  masses 
prevent  passage  of  the  gas  and  solid  feces,  excite  peristalsis  and  the 
hypersecretion  of  mucus,  augment  the  pathogenic  intestinal  bacteria 
and  their  toxins,  and  through  disturbance  of  the  circulation  lead  to  the 


Fig.  130. — Lane's  kink  at  the  ileocecal  juncture  formed  by  adhesions.     (After  author's 

case.) 


formation  of  stercoral  ulcers,  all  of  which  conditions  favor  diarrhea 
alone  or  alternating  with  constipation. 

Adhesions  (Fig.  130)  resulting  from  operations,  colitis,  appendicitis, 
and  suppurative  or  malignant  diseases  of  the  intestine  or  abdominal 
organs,  frequently  cause  chronic  intestinal  obstruction  characterized 


ETIOLOGY 


493 


by  gas  accumulation,  occasional  colic,  and  constipation  followed  by 
diarrhea. 

Strictures  and  tumors  which  press  upon  or  constrict  the  gut  or  pro- 
ject into  and  block  its  caliber  are  frequently  responsible  for  loose 
movements,  irrespective  of  the  etiology  behind  them. 

Angulations  (Fig.  131),  kinks,  and  twists  which  obstruct  the  intes- 
tine (particularly  the  colon  or  sigmoid  flexure)  to  a  marked  degree 
first  induce  constipation  and  later  diarrhea,  because  they  are  charac- 
terized by  coprostasis,  intestinal  irritability,  obstruction  and  retention 
of  offensive  feces,  discharges,  bacteria,  and  toxins,  all  of  which  tend  to 
augment  peristalsis  and  an  increased  secretion  of  mucus.     These  types 


Fig.  131. — Ptosis  and  angulation  at  the  hepatic  flexure.     Xote  how  the  bismuth  solution 
has  been  projected  by  the  enema  into  the  lower  ileum.     (Taken  by  Cole.) 

of  colonic  distortion  are  usually  secondary  to  a  pericolitis  or  sigmoiditis 
marked  by  the  formation  of  pericolic  membranes  (Jackson's)  or  ad- 
hesions (thread-,  band-like,  or  fan-shaped  adhesions)  consequent  upon 
organic  changes  inside  the  bowel,  or  inflammatory  or  suppurative  dis- 
ease within  the  eibdomen  or  pelvis. 

Diverticula  and  sacculations  of  the  colon  (diverticulitis  and  peri- 
diverticulitis) (Fig.  132)  and  sigmoid  flexure  and  rectoceles  which  attain 
considerable  size  provide  a  lodging-place  for  the  feces  that  collect  in 
an  amount  sufficient  to  induce  an  irritative  or  obstructive  diarrhea,  or 
such  pockets  may  become  occluded,  undergo  changes — diverticulitis  or 
peridiverticulitis — which  terminate  in  the  formation  of  an  abscess  and 
fistula  which  discharge  into  the  bowel  and  incite  septic  diarrhea. 


494 


OBSTRUCTIVE    (MECHANIC,    SURGICAL)    DIARRHEA 


Pericolitis  and  perisigmoiditis  from  whatever  cause  arc  invariably 
accompanied  by  the  formation  of  adhesions  (thread-,  band-,  fan-,  and 
sheath-Hke)   or  a  pericoHc  membrane   (Jackson's)    (Fig.    133)   which 

angulate,  dislocate,  compress  or 
einelop  the  colon,  impair  diges- 
tion, induce  auto-intoxication, 
fecal  impaction,  and  irritative 
diarrhea  or  enterospasm  (spastic 
constipation). 

Distortion  and  disease  of  the 
mesentery  has  been  known  to 
cause  acute  and  chronic  loose 
movements   by  obstructing  the 


Fig.  132. — Diverticula  of  the  colon  and 
sigmoid  flexure.' 


Fig.  133. — Membranous  pericolitis. 
Note  the  pseudoperitoneal  (Jackson's) 
membrane  which  binds  the  ascending 
colon,  cecum,  and  appendix  to  the  lateral 
parietal  peritoneum. 


gut  or  irritating  its  nerve  mechanism,  and  chronic  incarcerated  hernia 
has  in  rare  instances  produced  like  results. 

Invagination,  intussusception,  and  procidentia  recti  may,  when 
chronic,  induce  constipation  alternating  with  diarrhea  through  the 
retention  of  toxins,  obstruction  or  irritation  caused  by  them. 

Splanchnoptosis  and  etitero ptosis  (Fig,  134)  are  usually  complicated 
by  obstipation,  but  w^hen  the  colon  is  compressed  by  displaced  neigh- 
boring organs,  is  markedly  ptotic,  angulated,  and  twisted,  or  is  ex- 
tensively involved  by  pericolic  adhesions  or  membranes,  the  patient 
invariably  suffers  from  intermittent  attacks  of  or  continuously  from 
coprostatic  diarrhea. 

Congenital  and  acquired  dilatation  of  the  colon  invariably  induce 
obstipation  and  stercoral  diarrhea. 

1  Army  Med.  Museum. 


ETIOLOGY 


495 


Paralytic  ileus  frequently  terminates  fatally,  but  when  it  is  par- 
tial or  the  obstruction  has  been  complete,  but  has  been  relieved  and 
retained,  toxins  are  discharged  into  the  lower  bowel  and  toxic  diarrhea 
ensues. 

Ejiterospasm  incident  to  foreign  bodies,  offensive  discharges,  and 
inflammatory,  ulcerative,  or  obstructing  lesions  in  the  bowel  is  charac- 
terized in  the  beginning  by  complete  obstipation,  and  later  frequent 
fluid  evacuations,  which  immediately  follow  relaxation  of  the  intesti- 
nal musculature. 


Fig.  134. — Marked  ptosis  of  the  transverse  colon  wath  redundancy  of  the  sigmoid  fle.xure. 

(Taken  by  Cole.j 

Postoperative  seqiielce  and  intestinal  zvorms  which  distorted  (jr  blocked 
the  bowel  have  been  known  to  cause  constipation,  loose  movements, 
or  both. 

Hypertrophy  of  O'Beirnes  sphincter  (rectosigmoidal),  the  rectal 
valves,  levator  ani,  and  sphincter  muscle  have  one  and  all  been  responsible 
for  coprostatic  or  obstructive  diarrhea,  and  the  same  can  be  said  of 
anterior  coccygeal  deviation. 

Rectal  diseases — viz.,  tumors,  strictures,  hemorrhoids,  ulcers,  polypi, 
fissures,  procidentia,  or  fistulce — may  augment  the  frequency  and  flu- 
idity of  the  evacuations  by  blocking  the  bowel  or  exciting  peristalsis 
or  the  hypersecretion  of  mucus. 


CHAPTER   XLIII 

OBSTRUCTIVE   (MECHANIC,   SURGICAL)  DIARRHEA 

{Continued) 

SYMPTOMS 

The  symptoms  of  obstructive  diarrhea  depend  principally  on  its 
course,  duration,  and  the  degree  of  occlusion.  When  blocking  is 
almost  complete,  acute  constipation  ensues;  when  it  is  less  marked, 
chronic  constipation  and  diarrhea  are  induced.  The  symptoms  of 
the  former  are  more  violent  and  dangerous  than  the  latter,  which 
develops  slowly  and  seldom  completely  obstruct  the  bowel.  In 
acute  obstruction  cathartics  are  ineftective.  and  high  enemata  at  first 
bring  away  a  small  amount  of  feces,  and  are  returned  clear  thereafter. 
Persons  sufifering  from  acute  obstruction  frequently  have  a  desire  to 
evacuate  the  bowel,  but  pass  nothing  but  mucus.  This  type  of  cos- 
tiveness  is  most  common  in  childhood,  is  of  sudden  onset,  and  char- 
acterized by  continuous  pain  in  the  central  abdomen.  Unless  complete 
obstruction  is  promptly  relieved  the  patient  becomes  restless,  breaks 
out  in  a  cold  perspiration,  hiccups,  is  nauseated,  and  at  first  vomits 
the  stomach-contents,  then  bile,  and,  finally,  fecal  matter,  has  a 
furred  tongue,  facial  expression  of  distress,  weak,  thready  pulse, 
subnormal  temperature,  labored  respiration,  and  a  distended  and  ten- 
der abdomen.  Usually  peristalsis  is  violent,  and  the  intestinal  move- 
ments may  be  visible  or  felt  by  palpation  when  the  abdominal  wall 
is  thin.  When  the  block  is  not  promptly  relieved  the  patient  soon  dies 
from  exhaustion,  toxemia,  or  septic  peritonitis. 

Following  an  attack  of  acute  mechanic  obstruction,  patients  fre- 
quently suffer  from  chronic  constipation  as  a  result  of  the  paralyzed 
condition  of  the  intestine  incident  to  prolonged  distention  or  per- 
sistent diarrhea  which  may  prevail  where  toxins  are  virulent  or 
abundant. 

Chronic  mechanic  diarrhea  or  constipation  are  of  common  oc- 
currence and  encountered  more  frequently  in  adults  than  children, 
and  in  women  than  men. 

The  systemic  manifestations  of  chronic  obstruction  are  similar 
in  many  ways  to  those  of  diarrhea  resulting  from  improper  diet,  irregu- 
lar living,  catarrhal  and  ulcerative  colitis,  and  digestive  ailments,  but 
local  disturbances  van,-  with  the  nature  of  the  lesion  causing  the  occlu- 
sion. 

Chronic  obstructive  constipation  or  diarrhea  may  be  preceded  by 
peritonitis,  appendicitis,  typhoid  fever,  pelvic  inflammation,  injury,  sur- 
gical operation,  or  the  formation  of  adhesions,  but  most  frequently  they 
496 


CHRONIC    MECHANIC    DIARRHEA 


497 


arc  caused  by  one  or  more  lesions  of  the  Ijowel  which  impede  the  fecal 
current  except  when  caused  by  a  congenital  deformity.  The  patient 
usually  heis  enjoyed  good  health  until  the  bowel  began  acting  queerly 
and  the  stools  became  too  far  apart,  abnormal  in  shape,  or  frequent 
and  watery.  In  this  type  of  diarrhea  the  character  of  the  evacuations 
and  local  manifestations  depend  upon  the  part  of  the  bowel  involved 
and  nature  of  the  obstruction.  In  one  case  diarrhea  is  continuous, 
while  in  another  it  is  intermittent  or  alternates  with  constipation,  and 
there  may  be  periods  between  the  attacks  when  the  bowel  acts 
normally. 

Diarrhea  and  constipation  are  more  obstinate  when  the  obstruct- 
ing lesion  is  in  the  sigmoid  flexure  or  rectum  than  in  the  small  intestine 
or  upper  colon.  When  the  small  gut  is  blocked  the  feces,  owing  to 
their  liquid  state,  find  their  way  past  the  obstruction,  then  become  solid, 
but  usually  the  movements  are  thin  and  irregular.  When  the  sig- 
moid flexure  or  rectum  is  involved  the  evacuations  are  frequent,  the 
stools  are  liquid  or  semisolid  and 
irregular  in  shape,  and  the  patient 
constantly  feels  as  if  there  was 
something  in  the  lower  bowel  that 
ought  to  be  expelled  (Fig.  135). 

The  symptomatology  of  chronic 
obstruction  complicated  by  diar- 
rhea induced  by  congenital  deformi- 
ties, extra-intestinal  pressure,  peri- 
colic batids,  adhesions  and  tumefac- 
tions, abnormal  mesentery,  volvulus, 
kinks,  angulations,  and  hernia  is 
similar  in  many  respects.  Without 
previous  warning  the  bowel  begins 
to  act  irregularly  and  the  stools 
become  further  apart ;  at  first  a  daily 
stool  can  be  secured  by  the  aid  of 

fruit,  a  special  diet,  and  exercise,  but  later  constipation  becomes  more 
obstinate  and  mild  laxatives  are  required  to  obtain  a  satisfactory 
movement;  and,  finally,  frequent  copious  enemata  or  exceedingly 
strong  cathartics  are  necessary  to  secure  the  coveted  evacuation  and 
avoid  fecal  impaction.  When  unrelieved,  the  obstruction  increases  and 
obstipation  is  persistent  or  alternates  with  diarrhea,  and  evidences  of 
auto-intoxication  appear.  Finally,  when  the  lumen  of  the  gut  is  almost 
completely  closed,  the  mucosa  is  excoriated  (stercoral  ulcers),  the  colon 
above  the  obstructed  point  becomes  dilated,  and  diarrhea  prevails, 
because  only  liquid  feces  can  get  by  the  obstruction,  the  bowel  is  irri- 
table, and  aljnormal  peristalsis  and  glandular  activity  are  easily  excited. 

Patients  who  suffer  from  mechanic  chronic  constipation  or  diar- 
rhea sooner  or  later  complain  of  disturbed  digestion,  meteorism,  sen- 
sations of  weight  and  fulness  along  the  colon  or  in  the  rectum,  colic, 
pulling  pains,  headache,  loss  of  sleep,  nervous  phenomena,  etc. 
32 


Fig.  135. — Stricture  of  the  rectum  pro- 
duced by  a  large  urinary  calculus  which 
ulcerated  through  the  rectovesical  sep- 
tum.    (Removed  by  the  author.) 


498  OBSTRUCTIVE    (MECHANIC,    SURGICAL)    DIARRHEA 

Intestinal  stricture  (Fig.  136)  produces  vaning  symptoms,  depend- 
ing upon  the  degree  of  constriction  and  the  part  of  the  bowel  involved. 

Stenosis  of  the  small  intestine  does  not  occur  often,  seldom  pro- 
duces obstinate  obstipation,  diarrhea,  violent  peristalsis,  intestinal 
stiffening,  or  the  colicky  pains  frequently  witnessed  in  persons  afflicted 
with  constriction  of  the  colon  or  rectum.  Again,  in  occlusion  of  the 
small  bowel,  the  patient  complains  of  gastric  distention,  indigestion, 
nausea,  and  vomiting,  owing  to  backing  up  of  the  chyme  above  the 


Fig.   136. — Cylindric-celled    carcinomatous  stricture  of   the  rectum — the  mass  on  the 
right  shows  a  characteristic  crater-like  ulcer,     (.\fter  author's  case.) 

constriction,  a  condition  which  soon  leads  to  malnutrition  and  emaci- 
ation. 

Stricture  of  the  large  bowel  is  fairly  common,  and  is  encountered 
more  frequently  in  women  than  men,  and  oftener  in  patients  over  forty. 
In  the  beginning,  colonic  stricture  produces  a  slight  discomfort  in  the 
abdomen  difficult  to  locate.  Constipation  soon  begins  to  play  an 
important  role,  and  the  evacuations  become  irregular  or  delayed  except 
when  stimulated  by  fruit,  water  drinking,  and  exercise.  Shortly, 
mild  laxatives  are  indicated,  and  after  a  further  time,  strong  cathartics, 
purgatives,  alone  or  in  conjunction  with  enemata  of  oil  or  soapsuds. 
are  required  to  secure  daily  movements,  and.  finally,  when  the  con- 


BENIGN    AND    MALIGNANT    NEOPLASMS    OF    THE    INTESTINE        499 

striction  becomes  tight,  constipation  alternates  with  diarrhea  or  fre- 
quent evacuations  prevail,  and  prevention  of  fecal  impaction  is  difficult. 

When  once  stenosis  of  the  colon  or  sigmoid  flexure  is  fully  devel- 
oped the  patients  not  only  suffer  from  obstinate  constipation  and 
diarrheal  attacks,  but  also  from  poor  appetite.  They  also  complain 
of  irritable  stomach,  gas  colic,  have  sallow  complexions,  blotches  on 
the  skin,  loss  of  weight,  headaches,  nervousness,  lassitude,  neuralgias, 
and  other  manifestations  consequent  upon  copremia  or  the  absorption 
of  toxins,  abdominal  soreness,  local  tenderness  upon  pressure,  sensa- 
tions of  weight  and  fulness,  violent  peristalsis  (discernible  by  inspection 
through  the  fluoroscope  or  palpation),  intestinal  rigidity,  recurring 
fecal  impaction,  colitis,  mucus,  pus,  and  blood  in  the  stools,  and  a 
sensation  as  if  the  bowel  weis  blocked  at  a  definite  point. 

Stenoses  of  the  rectum  and  lower  sigmoid  flexure  are  accompanied 
by  the  above  symptoms  and  an  incessant  desire  to  empty  the  bowel, 
straining,  bearing-down  sensations  in  the  rectum,  tenesmus,  pain  in 
neighboring  organs,  the  sacrococcygeal  region  and  down  the  limbs, 
and  tape-  or  pipestem-shaped  stools. 

Usually  ulceration  is  more  marked  in  rectal  stricture,  the  stools 
foul  smelling,  more  frequent,  fluid,  and  contain  an  abundance  of  pus, 
blood,  and  mucus. 

In  nearly  all  cases  of  rectal  stenosis  the  patient  suffers  from  incon- 
tinence, owing  to  destruction  of  the  anal  muscle  by  disease  or  relaxa- 
tion of  the  sphincter  through  overwork,  and  fluid  feces  and  irritating 
discharges  constantly  dribble  through  the  anus  to  irritate  the  skin 
and  cause  pruritus. 

Enterospasm  is  of  sudden  onset  and  the  attacks  may  last  from  a 
few  moments  to  several  hours  or  days  and  cause  partial  or  complete 
occlusion,  constipation,  or  diarrhea.  At  such  times  the  bowel  can  be 
felt  through  the  abdominal  wall  as  a  hard-knotted  or  small  ridge-like 
tube,  and  the  patient  suffers  from  gas  distention,  cramping,  abdominal 
soreness,  rumbling  sounds,  and  obstipation  or  coprostatic  diarrhea. 

Intestinal  Parasites  '  Worms  i . — Subjective  and  objective  symptoms, 
aside  from  irregular  action  oi  the  bowel,  are  entirely  absent  in  certain 
cases,  whereas  other  patients  complain  of  distressing  crawling  sensa- 
tions in  the  abdomen,  cramps,  itching  of  the  anus  and  the  nose,  digest- 
ive disturbances,  anorexia  alternating  with  bulimia,  disturbed  sleep, 
extreme  ner\'ousncs<,  and  cr)nsupated  or  loose  mo\ements. 

Benign  and  malignant  neoplasms  of  the  intestine  (Fig.  137J  induce 
constipation  alternating  with  diarrhea,  frequent  straining,  and  about 
the  same  other  manifestations  as  stricture;  and,  in  addition,  cancer 
patients  suffer  from  cachexia,  enlarged  glands,  involvement  of  other 
organs,  a  more  rapid  loss  of  flesh,  severe  pain,  and  the  stools  have  a 
characteristic  nauseating  odor  and  contain  pus,  blood,  mucus,  pigment, 
and  shreds  of  tissue. 

The  symptoms  induced  by  foreign  bodies — enteroliths  and  fecal 
impactions — are  almost  identical,  viz.,  they  are  more  numerous  and 
distressing  when  the  offending  objects  are  multiple,  large,  irregular  in 


500  OBSTRUCTIVE    (MECHANIC,    SURGICAL)    DIARRHEA 

shape,  or  lodged  at  a  narrow  or  angulated  portion  of  the  gut.  than  when 
single,  small,  smooth,  and  located  in  the  free  intestine. 

In  the  beginning  there  is  constipation  alternating  with  diarrhea, 
but  when  the  bowel  becomes  blocked  by  an  impacted  mass  or  stone 
the  evacuations  become  fluid  and  escape  around  it.  The  stools  are 
offensive  and  contain  considerable  mucus,  alone  or  mixed  with  pus 
and  blood.  Impacted  fecal  masses  and  foreign  bodies  situated  in  the 
colon  and  sigmoid  flexure  induce  discomfort  in  the  abdomen,  excite 
frequent  and  prolonged  peristalsis,  and  interfere  greatly  with  diges- 
tion. When  situated  in  the  rectum  they  cause  dull  aching  pressure 
pain,  straining,  a  constant  desire  to  evacuate  the  bowel,  and  sacro- 
coccygeal pain  down  the  limbs  and  in  neighboring  organs,  frequent 


Fig.  137. — Simple  adenoma,  larger  than  a  man's  fist,  removed  by  operation  for  the 
relief  of  chronic  obstructive  constipation  and  diarrhea.  (Photograph.)  (Author's 
case.) 

micturition,  or  excite  the  levator  ani  and  sphincter  muscles  to  contrac- 
tion. 

Diverticula,  which  become  distended  and  press  upon  the  bowel 
or  obstruct  it.  cause  constipation  or  diarrhea,  and  when  inflamed 
induce  local  pain  and  symptoms  similar  to  those  of  appendicitis. 
Rectocele  causes  very  little  trouble  except  when  it  sers'es  as  a  trap  in 
which  the  feces  accumulate.  In  such  cases  it  induces  sensations  of 
weight,  fulness,  bearing-down  pains,  and  loose  movements  or  dribbling 
of  fluid  feces  through  the  anus. 

Splanchnoptosis. — General  or  aggravated  ptosis  of  special  organs 
reduces  the  patient  to  a  deplorable  state;  he  is  emaciated,  suffers  from 
malnutrition,  digestive  disturbances,  loss  of  appetite,  anemia,  cold 
extremities,  weak  pulse,  sinking  sensations,  dragging  pains  in  the 
abdomen,  a  pulsating  aorta,  tympanites,  colic,  occipital  and  temporal 
headaches,  a  bulging  or  pear-shaped  abdomen  with  thin  flabby  walls. 


PTOSIS    OF    THE    SIGMOID    FLEXURE 


501 


loss  of  fat  and  wcakt-ned  niusculalurc,  Dietl's  crises,  constipation, 
which  alternates  with  diarrhea,  and  when  the  enteroptosis  is  due  to 
separation  of  the  recti  muscles  the  patient  feels  as  if  the  abdominal 
contents  were  dropping  out. 

Ptosis  of  all  or  any  part  of  the  colon  is  alwiiys  accompanied  by 
constipation  and  fecal  impaction  or  coprostatic  diarrhea. 

Fecal  impaction  (Fig.  138)  causes  a  still  greater  displacement  of 
the  bowel,  pulling  pains,  backing  up  of  gases,  and  favors  the  formation 
of  adhesions,  causing  unnatural  positions  of  the  gut,  lessening  and  im- 
pairing its  function. 


Fig.  138. — Chronic  fecal  impaction  resulting  trom  an  angulation  in  the  descending 
colon  and  narrow  anal  canal.  The  sigmoid  flexure  is  packed  with  scybala  and  the  rectum 
filled  with  a  large  putty-like  mass.     (After  author's  case.) 


Ptosis  of  the  Sigmoid  Flexure. — The  author  has  treated  many 
patients  who  suffered  from  obstructive  diarrhea  caused  by  ptosis  of 
the  sigmoid.  In  some  cases  the  accompanying  obstipation  and  cop- 
rostatic diarrhea  were  dependent  on  massing  of  the  gut  in  the  pelvis, 
while  in  others  to  invagination  of  the  sigmoid  into  the  rectum.  The 
symptoms  arising  from  sigmoid  ptosis  or  invagination  are  fairly 
clear.  The  excrement  collects  in  the  sigmoid  and  becomes  impacted, 
causing  obstinate  constipation  alone  or  alternating  with  diarrhea, 
distention,  bulging,  tenderness,  sensations  of  weight,  and  dragging 
pains  in  the  left  iliac  and  pelvic  regions,  uterine  and  vesical  disturb- 
ances, occasional  discharge  of  jelly-like  or  stringy  mucus  or  offensive 
iluid  evacuations,  and  a  sensation  of  blocking  in  the  bowel. 


502 


OBSTRUCTIVE    (MECHANIC,    SURGICAL)    DIARRHEA 


Paralytic  Ileus. — This  type  of  obstruction  results  from  complete 
intestinal  occlusion  or  extensive  operations  upon  the  viscera,  the  bowel 
is  completely  inactive,  obstipation  is  complete,  and  the  condition  of 
the  patient  becomes  grave  and  he  suffers  from  nausea,  meteorism,  fecal 
vomiting,  and  a  rapid,  thready  pulse  until  he  is  relieved  or  dies.  In 
some  instances  the  bowel  is  only  partially  paralyzed,  when  the  symp- 
toms are  less  urgent  and  the  patient  complains  of  constipation,  diar- 
rhea, gas  pains,  and  the  usual  manifestations  of  partial  obstruction. 

Invagination  (Intussusception). — In  acute  invagination  the  bowel 
suddenly  becomes  blocked  and  the  patient  suffers  from  acute  abdominal 
pains,  distention,  rapid  pulse,  nausea  and  vomiting,  cold  perspiration, 


Fig.  139. — Showina 


chronic  invagination  of  the  sigmoid    flexion   into    the   rectum,  as 
viewed  from  below  through  the  proctoscope. 


partial  or  complete  obstipation,  subnormal  temperature,  and  indica- 
tions of  collapse. 

Chronic  invagination  occasionaUy  takes  place  at  the  ileocecal 
juncture,  but  the  sigmoid  flexure  telescopes  into  the  rectum  very  much 
more  frequently.  The  manifestations  of  this  condition  are  similar 
to  those  of  other  chronic  obstructive  lesions,  but  are  modified  accord- 
ing to  the  degree  in  which  the  gut  is  incarcerated.  Usually  the  patient 
suffers  from  constipation,  intermittenth'  or  all  the  time,  moderate 
tympanites,  local  tenderness  and  pain,  mucus  in  the  stools,  sensations 
of  weight,  fulness,  blocking  at  the  obstructed  point,  or  offensive  fluid 
evacuations  where  fecal  impaction  prevails. 


DISEASES    OF    THE    RECTUM    AND    ANUS  503 

When  the  sigmoid  is  invaginated  into  the  rectum  (Fig.  139),  the 
patient  has  an  incessant  and  unreHevable  desire  to  stool,  bearing- 
down  pains,  feehng  as  if  there  was  a  foreign  body  in  the  rectum, 
strains  terrifically  at  stool,  passes  more  or  less  mucus,  and  suffers  from 
persistent  constipation  or  diarrhea,  but  at  other  times  the  stools  are 
normal  and  the  patient  is  comfortable  except  for  the  annoyance  caused 
by  the  accompanying  catarrhal  inflammation. 

The  symptoms  of  congenital  and  acquired  dilatation  of  the  colon  re- 
semble those  of  splanchnoptosis — viz.,  the  feces  accumulate  in  con- 
siderable quantities  and  the  patient  complains  of  gas  distention,  indi- 
gestion, cardiac  disturbances,  nervous  phenomena,  nausea,  vomiting, 
and  obstipation  alternating  with  diarrhea. 

Hypertrophy  of  O'Beirne's  sphincter  is  accompanied  by  a  feeling 
of  tenderness,  weight,  and  blocking  of  the  gut  at  the  region  of  the 
rectosigmoid  juncture,  backing  up  of  feces  and  gas  in  the  colon,  and 
obstipation  or  diarrhea  according  to  the  degree  of  obstruction  caused 
b\'  the  muscle  and  the  presence  of  irritating  fecal  accumulations. 

Hypertrophy  of  the  rectal  valves  is  accompanied  by  the  accumu- 
lation of  feces  above  them,  which  forms  into  scybala  or  large,  firm,  or 
semisolid  masses  which  induce  pressure  pains,  desire  for  an  evacua- 
tion, with  imperfect  and  painful  defecation.  Ordinarily,  cathartics  are 
ineffective,  and  the  impacted  masses  must  be  removed  by  enemata  to 
prevent  them  completely  blocking  the  rectum  and  causing  fluid  evacua- 
tions. 

The  manifestations  which  accompany  hypertrophy  of  the  levator  ani 
and  sphincter  muscles  are  similar  to  those  just  enumerated,  with  the 
exception  that  the  blocking  is  not  constant,  owing  to  the  fact  that  the 
muscles  do  not  remain  in  a  continuous  state  of  contraction,  and  these 
patients  suffer  severely  from  sphincteralgia  or  sacrococcygeal  pain  as 
long  as  the  muscles  remain  rigid,  but  at  other  times  they  are  compara- 
tively comfortable. 

Diseases  of  the  rectum  and  anus  that  induce  constipation  or  cop- 
rostatic  diarrhea  in  addition  to  the  usual  symptoms  of  chronic  lower 
bowel  obstruction  may,  according  to  their  character,  be  accompanied 
by  pain  in  the  anal  region,  pruritus,  excoriation  of  the  skin,  tenesmus, 
sphincteralgia,  and  the  discharge  of  mucus  or  pus. 


CHAPTER  XLIV 

OBSTRUCTIVE   (MECHANIC,   SURGICAL)   DIARRHEA 

{Continued) 

DIAGNOSIS 

One  can  easily  differentiate  ordinary  from  obstructive  diarrheas, 
but  it  is  difficult  to  distinguish  between  the  various  intestinal  lesions 
responsible  for  chronic  loose  movements  and  obstipation. 

Obstruction  rarely  takes  place  in  the  small  bowel,  and  when  it  does, 
diarrhea  seldom  ensues,  because  the  feces  have  ample  time  to  become 
semisolid  or  firm  after  passing  the  block,  but  obstructive  lesions  are 
frequently  encountered  in  the  colon,  sigmoid  flexure,  and  rectum. 

Patients  afflicted  with  chronic  mechanic  (obstructive)  diarrhea 
usually  give  a  history  of  having  previously  suffered  from  indigestion, 
irregular  evacuations,  auto-intoxication,  ptomain-poisoning,  enteritis, 
catarrhal  or  specific  colitis,  peritonitis,  appendicitis,  diverticulitis,  etc., 
salpingitis,  or  suppurative  disease  within  the  abdomen,  etc.,  manifes- 
tations and  diseases  which  often  complicate  or  cause  adhesions,  peri- 
colic membranes,  kinks,  twists,  stricture  or  distortions  of  the  colon, 
and  surgical  diarrhea. 

In  such  cases,  when  loose  movements  prevail  or  alternate  with 
constipation  and  recurring  fecal  impaction,  the  sufferer  complains  of 
abdominal  soreness,  pain  on  pressure  at  a  given  point,  meteorism, 
one-sided  abdominal  distention,  cramps  unrelieved  by  an  evacuation, 
and  intestinal  auto-intoxication,  one  is  justified  in  diagnosing  the  case 
as  obstructive  diarrhea,  irrespective  of  whether  or  not  he  can  determine 
the  exact  nature  of  the  condition  responsible  for  the  block. 

Palpation,  succussion,  percussion,  auscultation,  and  distention  of 
the  colon  with  air,  gas,  or  water  materially  aid  in  the  diagnosis  when 
the  patient  is  made  to  change  his  position  during  the  examination, 
but  an  opinion  should  not  be  given  until  the  abdomen  has  been  ex- 
amined through  the  fluoroscope,  and  radiographs  have  been  made  of 
the  colon  following  the  administration  of  bismuth  meals  or  enemata. 

When  an  obstructing  lesion  has  been  located,  surgical  intervention 
is  indicated,  whether  its  character  is  known  or  not. 

Congenital  deformities  of  the  large  intestine  are  easily  located  at 
the  anus  or  in  the  rectum,  and  can  be  seen,  felt  with  the  finger,  or 
inspected  through  the  proctoscope.  Hirschsprung's  disease  and 
megacolon  are  recognized  by  the  accompanying  pot-belly,  long-delayed 
stools,  pasty  color  of  the  patient,  and  enormous  size  of  the  colon,  as 
revealed  by  palpation,  inflation,  fluoroscopic  examination,  radiographs, 
and  large  amount  of  water  it  will  hold.  Maljormatious  in  other  colonic 
504 


DIVERTICULA  505 

segmenis  may  be  suspected,  but  (-annot  be  positively  diagnosed  except 
by  lapar(jtomy  or  at  autopsy. 

Extra-intestinal  pressure  is  scjmetimes  demonstrable  by  physical 
examination,  fluoroscoping  or  x-raying  the  bowel,  and  by  obtaining 
a  histor>'  which  would  indicate  that  the  colon  is  being  involved  through 
the  extension  of  disease  or  a  tumor  from  neighboring  organs  or  struc- 
tures. 

Strictures  are  comparati\'ely  easy  to  diagnose,  owing  to  the  pre- 
vious histor\-,  which  will  show  that  the  patient  has  suffered  from 
typhoid,  ulcerative  colitis,  tuberculosis,  syphilis,  pelvic  or  abdominal 
suppuration,  or  other  affection  accompanied  by  a  destruction  of  the 
mucosa,  thickening  of  the  intestinal  tunics,  or  the  formation  of  ad- 
hesions which  press  upon  or  constrict  the  colon. 

Their  location  can  be  ascertained  with  the  finger  or  sigmoidoscope 
when  low,  and  by  enemata,  inflation,  the  fluoroscope,  or  radiographs 
when  high. 

Rectal  strictures  produce  sensations  of  fulness,  bearing  down,  inces- 
sant desire  to  stool,  and  pain,  which  are  unrelieved  by  an  evacuation. 

Benign  and  malignant  tumors  present  the  same  manifestations  as 
stenoses  similarh-  located,  but,  when  distinguishable  with  the  finger 
or  through  the  sigmoidoscope,  they  are  recognized  by  their  ovoid  or 
lobulated  or  pedunculated  form.  In  addition,  patients  suffering  from 
malignant  disease  are  markedly  cachectic  and  emaciated  and  the 
feces  are  often  typically  offensive. 

Intestinal  calculi  are  seldom  diagnosed  except  when  they  are 
evacuated  or  felt  in  the  rectum  in  patients  who  suffer  from  gall-stones, 
and  the  same  can  be  said  of  foreign  bodies  in  the  absence  of  a  history 
indicating  that  the  sufferer  has  swallowed  some  foreign  substance. 
In  a  few^  instances  intestinal  sand  has  been  accidentally  discovered 
while  the  fece-.  were  being  examined  for  some  other  condition. 

Fecal  impaction  complicates  all  forms  of  chronic  intestinal  obstruc- 
tion, and  scybala  can  usually  be  located  above  the  block.  Under  such 
circumstances  fecal  can  be  distinguished  from  other  tumors  by  their 
mobility,  indentability,  rapidly  increasing  size,  and  tendency  to  dis- 
appear following  the  administration  of  castor  oil  and  copious  soapsuds 
enemata  and  the  evacuation  of  scybala.  Large  fecal  masses  in  the 
lower  sigmoid  and  rectum  induce  pressure  pains,  tenesmus,  constant 
dribbling  of  fluid  feces,  and  can  be  felt  by  digital  examination  or 
inspected  through  the  proctoscope. 

Adhesions  are  diagnosed  by  getting  a  history  that  the  patient  has 
been  ojjerated  upon  or  suffered  from  an  acute  or  chronic  inflammatory 
process  within  or  without  the  bowel,  localized  distention,  discomfort, 
and  pulling  pains  when  he  changes  his  posture. 

Volvulus  (Fig.  140),  angulations,  and  kinks  should  be  suspected 
under  the  same  circumstances  because  they  cannot  be  difterentiated 
from  adhesions  except  by  radiography,  which   is  not  infallible. 

Diverticula  are  usually  discovered  by  accident,  since  they  do  not 
produce  symptoms  except  when  they  become  inflamed,  under  which 


5o6 


OBSTRUCTIVE    (MECHANIC.    SURGICAL)    DIARRHEA 


circumstances  they  cause  manifestations  simulating  those  of  appendi- 
citis except  that  the  locahzed  soreness,  pain,  and  muscular  rigidity  is 
in  the  sigmoidal  region,  which  is  the  segment  of  gut  most  often  the  site 
of  diverticula.  During  acute  crises  constipation  is  marked,  the  tem- 
perature is  irregular,  and  a  swelling  can  be  seen  or  felt  in  the  lower  left 
abdominal  quadrant,  and  where  perforation  ensues  the  usual  symptoms 
of  abscess  or  peritonitis  are  present.  Sacs  in  the  lower  sigmoid  and 
rectum  can  be  detected  with  the  finger  or  proctoscope  by  their  open- 
ings into  the  bowel  through  which  pus  escapes. 


Fig.  140. — Volvulus  complicating  a  redundant  sigmoid  flexure.     (Taken  by  Cole.) 


Enlarged  colonic  sacculations,  which  cannot  be  diagnosed  by  radio- 
graphs, fluoroscopic  examination,  or  palpation,  cannot  be  positively 
identified  except  by  inspection  following  celiotomy. 

Rectoceles  are  easily  diagnosed  owing  to  the  facility  with  which 
they  can  be  examined. 

Pericolitis  and  perisigmoiditis  are  usualK-  caused  by  inflammator>' 
or  obstructive  bowel  lesions  or  disease  within  the  abdomen,  and  it  is 
necessary  to  get  a  good  history  of  the  case.  Pericolitis  with  adhesions 
or  a  pericolic  membrane  can  sometimes  be  diagnosed  by  fluoroscopic 
examination  made  while  the  colon  is  manipulated  with  the  fingers  to 
determine  if  it  is  fixed.    Radiographs  are  helpful  in  locating  the  trouble, 


HIRSCHSPRUNG  S    DISEASE  507 

but  arc  not  reliable  for  differentiating  pericolitis  from  other  chronic 
ol)slruc~tin.L;  k'sions  of  the  colon. 

Internal  herniae  and  mesenteric  disease  causing  intestinal  obstruc- 
tion may  be  suspected,  but  it  is  impossible  to  diagnose  them  without 
opening  the  abdomen. 

Chronic  invagination  (intussusception)  has  been  known  to  occur 
at  the  ileocecal  juncture,  but  in  the  vast  majority  of  cases  the  sigmoid 
(Fig.  141)  is  involved  and  projects  into  the  rectum.  The  latter  type 
of  invagination  is  easily  diagnosed  because  the  displaced  gut  can  be 
seen  through  the  proctoscope,  which  it  follows  to  the  anus  when  the 
patient  strains  as  it  is  withdrawn.  Patients  thus  aflflicted  complain  of 
obstipation,  left-sided  block,  itching,  soreness,  gas  distention,  and  say 
that  water  injected  into  the  colon  does  not  return  promptly  if  at  all. 
On  the  days  when  invagination  does  not  take  place  the  subject  feels 
comfortable  and  is  not  constipated. 


Fig.  141. — Invagination  of  sigmoid  flexure  into  the  rectum. 

Splanchnoptosis  and  enteroptosis  are  comparatively  easy  to  recog- 
nize ow'ing  to  the  patient's  emaciated  condition,  relaxation  of  his  tis- 
sues, constipation,  muddy  complexion,  pulling  pains,  bulging  abdomen, 
melancholia,  inactive  mind  and  muscles,  and  by  palpating  and  per- 
cussing the  abdomen,  which  will  reveal  that  the  organ,  or  viscera  are 
not  in  their  normal  position.  When  the  diagnosis  is  still  doubtful 
one  should  resort  to  colonic  inflation,  fluoroscopy,  radiography,  or 
laparotomy. 

Colonic  dilatation  (Fig.  142)  can  be  differentiated  from  other  chronic 
obstructions  by  inflating  the  bowel  with  air  and  defining  the  position 
by  pal|)ating  and  percussing  the  abdomen. 

Hirschsprung's  disease  (congenital  colonic  dilatation),  observed 
in  young  children,  is  characterized  by  malnutrition,  pot-belly,  ob- 
stinate constipation  and  coprostasis,  the  stools  frequently  being  days, 
weeks,  or  months  apart.  The  colon  is  large,  thick,  and  can  be  clearly 
defined  by  palpation  and  percussion  follcnving  its  inflation  with  air.  or 


508  OBSTRUCTIVE    (MECHANIC,    SURGICAL)    DIARRHEA 

with  the  fluoroscope  and  radiographs  subsequent  to  the  administra- 
tion of  bismuth  meals  or  enemata. 

Enterospasm  should  be  suspected  where  the  intestine  is  irritable, 
inflamed,  or  blocked,  and  the  patient  suddenly  suffers  from  complete 
obstruction.  Usually  a  semisolid  or  firm  tumor  (contracted  bowel) 
can  be  outlined  at  the  site  of  the  trouble  above  where  gas  and  feces 
have  collected.  When  the  swelling  and  symptoms  disappear  follow- 
ing the  administration  of  belladonna,  applications  of  hot  fomentations 


Fig.  14.2. — Enormously  ptotic  and  dilated  cecum  with  enlargement  of  the  ascending 
colon.  Note  how  the  enema  projected  the  bismuth  solution  for  several  feet  into  the  small 
intestine,  indicating  ileocecal  valve  incompetence.     (Taken  by  Cole.) 

and  copious  soapsuds  or  hot  oil  injections,  a  diagnosis  of  enterospasm 
is  justifiable. 

Intestinal  parasites  seldom  cause  obstruction,  but  when  they  do.  the 
history  will  show  that  the  patient  has  previously  passed  whole  or  seg- 
ments of  worms.  Examination  of  the  stools  for  pieces  of  parasites  and 
their  ova  is  indicated  when  helminths  are  suspected. 

Hjrpertrophy  of  O'Beime's  sphincter  can  be  diagnosed  by  introduc- 
ing the  sigmoidoscope  and  inflating  and  defining  the  size  of  the  recto- 
si'^moidal  JHucturc  with  soft-rubber  bougies. 

Enlarged  rectal  valves  are  easily  seen  through  the  proctoscope,  and 


HEMOkRIlOIUS  509 

when  they  are  rigid  and  feces  can  be  seen  resting  upon  their  upper  sur- 
face tliey  (lela\'  or  prexent  normal  e\-;icuations. 

Hypertrophy  of  the  levator  ani  muscle  can  be  detected  by  digital 
examination.  In  such  cases  the  muscle  is  greatly  increased  in  size 
iind  grasps  the  finger  tightly,  aliout  2  inches  above  the  einus,  when 
introduced  into  the  rectum.  The  muscle  blocks  the  rectum  and  leads 
to  coprostasis  or  fragmentary  constipation,  heaviness,  or  dull  aching 
pain  in  the  lower  bowel,  vesical  irritability,  and  a  shutting-off  sensa- 
tion just  when  the  feces  are  about  to  be  evacuated. 

A  deformed  or  fractured  coccyx  is  quickly  recognized  by  the  local- 
ized pain,  finding  out  if  the  patient  has  had  a  fall,  and  by  inserting  the 
finger  into  the  bowel  and  grasping  the  coccygeal  lip  between  the 
thumb  and  finger  so  that  it  can  be  manipulated. 

Hypertrophy  of  the  sphincter  muscle  causes  constipation,  difficult 
defecation,  sphincteralgia,  and  contraction  of  the  anus,  which  when 
stretched  causes  intense  pain. 

Hemorrhoids  are  diagnosed  by  their  bleeding,  protrusion,  and 
tumor-like  formation;  fissure,  by  its  slit-like  shape  and  the  sphincter- 
algia which  it  induces. 


CHAPTER  XLV 

OBSTRUCTIVE   (MECHANIC,   SURGICAL)   DIARRHEA 

{Concluded) 

TREATMENT  (NON-OPERATIVE— PALLIATIVE,  SURGICAL) 

The  treatment  of  mechanic  or  obstructive  diarrhea  is  no7i-operative 
and  surgical,  but  the  former  only  makes  the  patient  more  comfortable 
and  extends  life,  while  the  latter  is  curative,  and  should  be  practised  as 
soon  as  the  patient's  consent  can  be  obtained,  unless  he  is  unable  to 
withstand  operation. 

Non-operative  Treatment. — The  palliative  treatment  of  diarrhea 
incident  to  obstructing  lesions  consists  chiefly  in  (a)  regulating  the 
diet  so  that  the  bulk  of  the  excreta  is  diminished  and  the  feces  are  non- 
irritating;  (b)  prescribing  antiseptics,  astringents,  and  opiates  by  mouth 
to  lessen  fermentation  and  putrefaction,  attenuate  or  destroy  patho- 
genic intestinal  bacteria  (or  counteract  the  effect  of  their  toxins), 
diminish  the  evacuations,  and  relieve  pain  and  cramps;  (c)  adminis- 
tering castor  oil  when  loose  movements  are  due  to  coprostasis  and  fre- 
quent colonic  medicated  irrigation  to  minimize  the  effects  of  auto-in- 
toxication, wash  out  foul  discharges,  toxins,  and  bacteria,  dissolve  and 
flush  out  irritating  feces,  and  heal  the  inflamed  and  ulcerated  mucosa 
above  and  below  the  obstruction ;  (d)  prescribing  nerve,  blood,  or  general 
tonics  to  improve  the  patient's  condition;  and  (e)  having  the  sufferer 
refrain  from  worrying,  taking  violent  exercise,  remaining  in  the  sun, 
eating  ice-cream  or  shell-fish,  indulging  in  alcoholic  beverages,  and 
consuming  articles  of  diet  known  to  disagree  with  him. 

By  following  this  plan  of  treatment  many  patients  can  be  markedly 
improved  and  think  they  are  on  the  road  to  recovery  when  such  is 
not  the  case,  because  permanent  relief  is  not  to  be  expected  until  the 
lesion  causing  chronic  obstruction  has  been  corrected  or  removed. 
The  author  informs  the  sufferer  what  he  may  expect,  and  lets  him 
decide  whether  he  prefers  temporary  help,  through  palliative  meas- 
ures, or  a  permanent  cure,  which  cannot  be  accomplished  except 
through  operative  interference.  When  the  facts  have  been  fully  ex- 
plained, the  average  patient  will  insist  upon  an  operation,  because  he 
knows  from  experience  that  he  cannot  obtain  a  cure  by  less  radical 
measures. 

The  reader  is  referred   to   the  chapters  devoted   to  the  surgical 
treatment  of  diarrhea   for   a  detailed  description    of  the  operations 
frequently    employed    in    the    treatment  of    obstructive  or    surgical 
diarrhea. 
510 


SURGICAL    TREATMENT  51I 

Surgical  Treatment. — Obslructive  diarrhea  has  a  complex  etiology, 
and  different  operations  (simple  or  difficult)  are  reciuired  lo  relieve  and 
cure  it  in  a  series  of  cases.  Most  of  the  procedures  recjuired  for  the 
purpose  can  be  quickly  performed,  are  principally  devoid  of  danger, 
and  bring  al)out  surj^risingly  good  results. 

Congenital  dcjormities  of  the  rectum  and  anus  are  fairly  common, 
while  malformations  of  the  colon  and  sigmoid  are  rare,  and  seldom 
recogniy.ed  until  it  is  too  late.  Palliative  measures  should  be  tried  in 
cases  of  partial  obstruction,  but  where  the  colon  is  almost  or  completely 
blocked,  in  consequence  of  abnormalities  or  sequela?  incident  to  an 
attempt  to  cure  them,  surgical  intervention  is  imperative,  and  the 
deformity  or  distortion  should  be  forthwith  corrected  or  removed  by 
the  procedure  indicated. 

Congenital  narrowing  or  stricture  at  the  anus  is  relievable  by  for- 
cible divulsion,  but  division  of  it  and  the  sphincter,  followed  by  drainage 
and  occasional  insertion  of  the  finger,  give  quicker  and  more  lasting 
results. 

When  the  anal  aperture  or  rectum  is  partially  or  completely  oc- 
cluded hy  fibrinomembrauous  partitions  they  are  gotten  rid  of  best  by 
seizing  and  dissecting  them  free  from  the  bowel  with  knife  or  scissors. 

Imperforate  anus,  where  the  rectum  terminates  in  a  blind  pouch  at 
or  just  above  the  anus,  can  be  corrected  by  incising  the  occluding  struc- 
ture at  the  anal  site  quickly  and  without  disturbing  the  sphincter  if 
present.  When  the  culdesac  terminates  an  inch  or  more  above  the 
anus  or  the  lower  rectum  is  strictured,  dissections  should  be  carried 
from  below  upward,  so  that  the  terminal  end  of  the  bowel  can  be  freed, 
brought  down,  and  sutured  at  the  anal  site,  with  preservation  of  the 
sphincter,  but  where  this  is  not  feasible,  and  there  is  no  sphincter,  a 
new  anus  is  established  at  the  most  convenient  point,  which  occasion- 
ally necessitates  removal  of  the  coccyx. 

In  cases  of  imperforate  amis  with  a  fecal  fistula  opening  into  the 
vagina,  bladder,  urethra,  or  surface  of  the  body,  the  operation  must  be 
varied  according  to  indications.  Where  the  rectum  ends  in  the  vulva 
or  vagina,  the  sinus  or  anus  and  the  sphincter  when  falsely  implanted, 
are  freed  through  an  incision  carried  backward  and  the  lower  rectum  or 
sphincter  are  restored  to  their  normal  position  and  a  modified  procedure 
is  indicated  in  the  presence  of  surface  recto-urethral  and  rectovesical 
fistulse. 

If  the  fistulous  opening  is  large  and  satisfactory  evacuations  take 
place,  operative  interference  may  be  indefinitely  postponed,  or  tlie 
deformity  or  sequehe  may  be  corrected  at  once,  except  in  infants  and 
young  children,  who  withstand  such  operations  badly.  In  deplorable 
cases,  where  as  the  result  of  congenital  deformities  of  the  colon,  rectum, 
or  anus  or  their  sequekr,  the  bowel  cannot  be  replaced  and  the  patient 
have  sphincteric  control,  an  artificial  opening  should  be  made  abo\e 
the  block. 

Extra-intestinal  pressure  causing  diarrhea  ma>-  be  induced  by  ad- 
hesions which  constrict  the  intestine,  intra-abdonunal  tumor,  dis])laced 


512 


OBSTRUCTIVE    (MECHANIC,    SURGICAL)    DIARRHEA 


organ,  or  enlarged  prostate,  under  which  circumstances  adhesions 
should  be  divided.  Neoplasms  should  be  excised,  the  uterus  restored 
to  its  normal  position  and  fixed,  or  the  prostate  removed. 

Strictures  of  the  small  intestine  and  colon  responsible  for  chronic 
loose  movements  require  excision,  but  when  this  is  not  feasible,  owing 
to  the  patient's  debilitated  condition,  complications  or  number  of  sten- 
oses, the  blocked  segment  of  gut  should,  according  to  indications,  be 
excluded  by  short-circuiting  or  unilateral  (Fig.  143)  or  bilateral  exclusion. 
Strictures  of  the  lower  rectum  may  be  treated  by  divulsion  or  division 
(proctotomy)  to  increase  the  bowel  lumen,  procedures  contra-indicated 
when  narrowing  is  in  the  upper  rectum  above  the  peritoneal  attach- 
ment. In  obstinate  and  previously  operated  cases  the  diseased  rec- 
tum should  be  amputated,  and  the  proximal  end  of  the  gut  sutured  to 

the  skin  within  the  sphincter.  Ownng  to 
its  objectionable  features,  colostomy  should 
not  be  performed  except  when  for  any 
reason  the  above  procedures  are  imprac- 
ticable. 

Benign  and  malignant  tumors  frequently 
cause  mechanic  diarrhea,  which  continues 
until  they  are  excised,  isolated  by  exclu- 
sion, or  an  artificial  anus  is  made  in  the 
colon  above  them — procedures  described 
elsewhere. 

Resection  is  the  operation  of  choice 
when  the  growth  is  in  the  colon  or  sig- 
moid, because  it  is  not  very  dangerous  and 
offers  the  only  hope  of  a  permanent  cure. 
Lateral,  with  a  large  opening,  is  preferable 
to  end-to-end  anastomosis,  since  the  latter 
frequently  results  in  stricture  and  return  of 
the  diarrhea. 

Rectal  cancers,  according  to  their  loca- 
tion, may  be  removed  by  perineal,  vaginal, 
or  sacral  (Kraske)  proctectomy  when  located  in  the  lower  or  middle 
rectum,  and    by   the  combined   operation   (perineo-abdominal)    when 
situated  in  the  lower  sigmoid  or  rectosigmoid  juncture. 

Inoperable  colonic  growths  should  be  excluded  because  patients 
prefer  this  procedure  to  colostomy,  which  is  imperative  in  the  presence 
of  irremovable  rectal  cancers. 

Polypi  when  large  and  numerous  should  be  treated  as  other  tumors 
of  the  colon,  but  when  they  are  single  and  situated  in  the  rectum  they 
are  easily  removed  by  the  ligature  or  clamp-and-cautery  operation, 
linear  excision,  or  by  attaching  the  author's  valve  clamp  to  their  base 
and  letting  them  slough  off. 

Foreign  bodies  irritating  the  bowel  can  occasionally  be  dislodged  and 
evacuated  through  the  aid  of  copious  enemata,  but  w^hen  lodged  or 
encysted  in  the  small  intestine  or  colon,  entcrostomv,  colostomy,  or,  in 


Fig.  143. — Unilateral  exclu- 
sion (ileorectostomyj  for  the  re- 
lief of  inoperable  carcinoma  of 
descending  colon.  Excluded 
segment  of  bowel  drained  by 
cecostomy.  (After  author's 
case.) 


SURGICAL    TREATMENT  513 

rare  instances,  resection  is  necessary  to  remove  them.  Foreign  bodies 
in  the  rectum  can  be  located  and  removed  through  the  proctoscope  if 
free,  but  when  encysted  or  they  have  sharp  angles  the  sphincter  should 
be  divulsed  to  give  more  room,  and  the  bowel  should  be  protected  as 
they  are  drawn  downward  with  forceps.  In  rare  instances  colostomy 
is  indicated  to  provide  a  vent  for  the  feces  above  them. 

Fecal  impaction  recurs  above  lesions,  causing  obstructixc  diarrhea 
until  they  are  removed,  but  when  it  is  incident  to  atonic  constipation 
and  a  fecal  mass  of  considerable  size  or  scybala  form  and  induce  cop- 
rostatic  diarrhea,  relief  quickly  follows  removal  of  the  feces  through 
the  aid  of  massage  and  liberal  doses  of  castor  oil  reinforced  by  copious 
high  soapsuds,  oil,  or  hydrogen  peroxid  (25  per  cent.)  enemata.  Im- 
pacted masses  within  the  sigmoid  and  rectum  can  be  broken  up  through 
the  proctoscope  when  high,  or  by  the  finger  when  near  the  anus,  after 
which  the  rectum  can  be  quickly  evacuated  by  irrigation. 

Adhesions  vary  in  form  and  density  and  the  technic  of  their  remo\"al 
varies.  When  obstruction  is  caused  by  recent  thread-like  adhesions 
or  exudates,  which  constrict  or  glue  the  gut  to  adjacent  structures, 
diarrhea  from  this  source  can  be  relieved  by  Vjreaking  them  up  with  the 
aid  of  massage,  vibratory  treatments,  and  certain  exercises,  but  when 
the  colon  is  blocked  by  organized  fibrous  band-  or  sheath-like  adhe- 
sions operative  interference  is  indicated.  To  avoid  injury  to  the  gut  and 
complications,  the  involved  bowel  should  be  fully  exposed,  so  that  exu- 
dates and  adhesions  can  be  separated  or  removed  by  careful  dissection 
or  wiping  the  intestine  from  side  to  side,  and  not  by  freeing  them  with 
the  finger  within  the  abdomen.  Their  possible  subsequent  re-forma- 
tion can  usually  be  prevented  by  suturing  or  covering  tears  in  the  peri- 
toneum, floating  the  intestine  with  sterile  oil  or  a  normal  salt  solution 
before  closing  the  wound,  and  later  prescribing  a  drug  which  stimulates 
peristalsis,  and  having  the  patient  change  his  posture  frequently  to 
prevent  the  bowel  from  remaining  too  long  in  the  same  posture.  Where 
adhesions  are  numerous,  strong,  involve  a  considerable  segment  of  the 
colon,  and  cannot  be  removed  or  destroyed,  resection  or  exclusion  is 
indicated,  and  when  either  of  these  is  not  feasible,  an  artificial  anus 
should  be  established  in  the  free  bowel  above. 

Pericolic  (Jackson's)  membranes  act  similarly  to  adhesions,  but 
can  be  eliminated  by  ligating  and  dividing  their  extremities  and  then 
peeling  them  free  from  the  colon.  Where  this  cannot  be  accomplished, 
excision,  exclusion,  or  colostomy  must  be  substituted. 

Angulations  and  twists  (volvulus)  responsible  for  obstructive  diar- 
rhea frequently  require  the  same  treatment  as  adhesions,  since  they 
are  caused  by  them,  but  when  incident  to  rotation  or  ptosis  of  the 
colon,  a  distorted  segment  of  bowel  should  be  straightened  out,  replaced, 
and  anchored  in  its  normal  position  (sigmoidopexy,  colopexy).  In 
deplorable  cases,  where  the  bowel  is  inseparably  adherent  to  and  massed 
in  the  pelvis  with  other  viscera,  extensive  resection,  exclusion,  or 
colostomy  are  unavoidable. 

Chronic  invagination  of  the  sigmoid  (Fig.  141 )  has  been  frequently 

33 


514 


OBSTRUCTIVE    (MECHANIC,    SURGICAL)    DIARRHEA 


encountered  by  the  author,  and  where  it  induced  diarrhea  alone  or 
alternating  with  constipation  quick  and  usually  permanent  relief  has, 


Fig.  144. — Ptosis  of  the  sigmoid  flexure  is  shown  in  the  small  drawing,  and  its  replace- 
ment and  fixation  (circular  colopexyj  in  the  larger  one.     (Author's  case.) 


Fig.  145. — Dotted  lines  indicate  the  size  of  the  dilated  colon.  The  untied  Lembert- 
like  sutures  show  the  way  in  which  the  bowel  is  infolded  and  the  peritoneal  surfaces 
of  the  gut  are  brought  in  contact,  and  the  tied  stitches  how  the  intestine  is  anchored  to 
the  abdominal  parietes. 

in  the  majority  of  instances,  followed  its  withdrawal  and  fixation  to 
the  anterior  or  posterior  abdominal  parietes.  Where  other  organs 
were  ptotic  they  were  also  anchored  where  they  belonged. 


SURGICAL    TREATMENT 


515 


Congenital  and  acciuired  colonic  dilatation  (Fig.  145)  is  best  con- 
trolled by  coloplication  reinforced  by  colopexy,  but  where  the  enlarged 
gut  is  displaced  or  completely  incapacitated  by  adhesions,  colectomy 
or,  preferably,  ileosigmoidostomy  should  be  performed,  otherwise  a 
permanent  cure  cannot  be  obtained. 

Diverticula  of  the  colon  and  sigmoid  that  induce  diarrhea  can  be 
eliminated  or  removed  by  the  ligature,  cautery,  excision  or  inversion, 
and  suture  when  few  and  small,  but  when  inflamed,  large  or  multiple, 
as  frequently  encountered  in  the  sigmoid,  the  involved  segment  of  gut 
should  be  excised.  Short-circuiting  and  colostomy  are  contra-indicated 
except  in  extreme  cases  or  where  perforation  has  occurred  resulting  in 
abscess  and  fistula.  Fistulous  sinuses  should  be  dissected  out,  the 
pus  cavity  emptied,  cleansed  and  drained, 
and  then  the  opening  in  the  bowel  should 
be  closed. 


Fig.  146. — Dotted  lines  indicate  extensive 
V-shaped  ptosis  of  the  transverse  colon;  the 
shaded  area  the  point  where  the  feces  col- 
lect in  it,  and  the  stitches  how  the  colon  is 
anchored  to  the  abdominal  wall  (colopexy). 


Fig.  147. — Intestinal  exclu- 
sion (ileosigmoidostomy)  for  M- 
shaped  colonic  ptosis  with  angu- 
lation of  the  splenic  and  hepatic 
flexures.  Cecum  and  ascending 
colon  drained  by  dppendicos- 
tomy  and  the  transverse  colon 
by  ileocolostomy.  (After  au- 
thor's case.) 


Splanchnoptosis,  enteroptosis,  and  coloplosis  frequently  lead  to 
constipation  and  coprostatic  diarrhea,  which  continue  until  tlie  colon 
and  other  organs  have  been  returned  and  fixed  in  their  normal  position 
by  colopexy  (Fig.  146),  si^moidopexy,  splenopexy,  hepatopexy,  or 
nephropexy.  Where  all  the  large  intestine  is  down,  it  is  necessary  to 
attach  it  to  the  abdominal  parietes  at  a  number  of  points  to  forestall 
angulation  and  sagging,  and  where  it  is  markedly  displaced  and 
firmly  bound  down  by  adhesions  it  is  advisable  to  exclude  it  by  joining 
the  lower  ileum  to  the  sigmoid  flexure  or  rectum  (ileosigmoidostomy 
or  rectostomy.  Fig.  147).  Following  restoration  of  the  organs,  con- 
valescence can  be  hastened  l)y  having  the  patient  wear  a  suitable 
binder  and   resort  to  massage,  vibratory  treatment,  electricity,  and 


5i6 


OBSTRUCTIVE    (MECHANIC,    SURGICAL)    DIARRHEA 


hydrotherapy,  to  strengthen  the  bowel  and  clear  up  manifestations 
incident  to  intestinal  auto-intoxication. 

For  a  full  description  of  the  author's  colopexy  and  sigmoidopexy 
the  reader  is  referred  to  his  work  upon  "Intestinal  Stasis." 

Obstruction  from  parasites  {worms)  can  usually  be  relieved  by  pur- 
gation, vermifuges,  and  medicated  irrigations  introduced  from  below 
or  through  an  appendicostomy.  cecostomy.  or  colostomy  opening. 
In  a  few  instances  worms  blocking  the  bowel  could  not  be  expelled, 
and  it  was  necessan.-  to  resect  the  gut  or  establish  an  artificial  anus  to 
eliminate  them  and  save  the  patient's  life. 

Enterospasm,  as  ordinarily  encountered,  can  be  speedily  relieved 
bv  having  the  patient  drink  an  abundance  of  hot  water,  apply  hot 
fomentations  to  the  abdomen,  and  take  several  copious  high  warm 
enemata,  all  of  which  favor  relaxation  of  the  intestinal  musculature. 
When  relief  does  not  follow,  they  should  be  reinforced  by  the  admin- 


GANT'S  \3\\e    Clamp  Applicator 

3E 


\'alvc 
Clam 


Colostomy 
Clamp 


Fig.  i4S.^Author's  valvotomy  instruments  (clamps  and  applicator).  The  drawings 
show  the  applied  clamp  through  the  proctoscope  and  appearance  of  the  ulcerated  valve 
edges  after  it  has  cut  its  wav  out. 


istration  of  belladonna,  mi  x  (0.60).  administered  three  or  four  times 
daily,  until  the  enterospasm,  colic,  and  constipation  or  diarrhea  have 
been  relieved.  OccasionalK"  an  opiate  is  required  to  relieve  suffer- 
ing, induce  sleep,  or  check  frequent  movements. 

Hypertrophy  of  O'Beirne's  sphincter  at  the  rectosigmoid  juncture 
has  been  known  to  cause  obstructive  diarrhea.  Under  such  circum- 
stances the  narrow  gut  should  be  distended  with  an  inflating  bag,  or 
w'here  the  mucosa  is  inflamed  or  ulcerated,  contraction  of  the  gut  in- 
cident to  the  lesions  can  be  alleviated  or  arrested  by  irrigating  the 
bowel  with  a  hot  ichthyol,  balsam  of  Peru,  or  permanganate  (i  per 
cent.)  solution  of  warm  high  oil  enemata  containing  bismuth.  In  a 
chronic  case  of  the  author's  resection  became  imperative. 

Hypertrophied  rectal  (Houston's)  valves  are  occasionally  responsible 
for  stercoral  diarrhea,  in  which  case  the  division  of  one  or  more  valves 
is  indicated.  Almost  universal  success  has  followed  the  author's 
valvotomy.     The  technic  of  applying  his  valve  clamp  can  be  readily 


SURGICAL    TREATMENT 


517 


understood  by  a  glance  at  the  accompanying  illustration  (Fig.  148). 
The  middle  valve  usually  causes  the  obstruction,  and  division  of  the 
others  is  seldom  required. 

Hypertrophy  of  the  anal  sphincter  muscle  was  formerly  treated  by 
forcible  divulsion  under  ether,  but  experience  has  taught  the  author 
that  better  and  more  permanent  results  are  obtained  when  the  muscle 
is  divided  under  local  anesthesia. 

Fissure  in  ano  invariably  causes  sphincteralgia,  and  usually  cannot 
be  cured  until  the  anal  muscle  has  been  divulsed  or  severed.  The 
author  prefers  the  latter  because  a  cure  follows  more  promptly  and  the 


Fig.  149. — Metlind  ..i  rMniilini:  hfmorrlnucl^  in  the  author'-  l.ual  aiic-tluMa  oi>eralion. 


anal  outlet  is  permanently  widened  so  that  defecation  is  facilitated. 
When  the  patient  declines  operative  interference,  one  can  sometimes 
heal  the  rent  by  keeping  the  feces  soft  and  making  mild  (6  per  cent.)  sil- 
ver or  ichthyol  topical  applications. 

Hemorrhoids  seldom  induce  constipation  or  diarrhea,  but  when  they 
do,  the  internal  variety  should  be  removed  by  the  clamp-and-cautery 
or  ligature  operation  under  local  anesthesia  (Fig.  149).  Skin-tags  can 
be  quickly  gotten  rid  of  liy  snipping  them  off  with  scissors  and  suturing 
or  permitting  the  wounds  to  heal  by  granulation,  and  thrombotic  hem- 


51 8  OBSTRUCTIVE    (MECHANIC,    SURGICAl)    DIARRHEA 

orrhoids,  by  slitting  them  open,  evacuating  the  clot,  and  inserting  a 
drain. 

Rectal  polypi  in  the  lower  rectum  are  easily  eliminated  by  excision, 
the  ligature,  or  clamp-and-cautery  operation,  but  when  situated  high 
they  should  be  removed  with  a  snare,  by  torsion,  or  with  the  author's 
valve  clamp,  which,  when  applied  at  their  base,  causes  them  to  drop 
off  through  pressure  necrosis. 

Procidentia  recti,  moderate  in  degree,  can  be  corrected  by  linear 
cauterization  or  the  removal  of  segments  of  the  mucosa  with  the  liga- 
ture or  knife  under  local  anesthesia.  In  extreme  cases  the  author  first 
removes  a  segment  of  the  rectum,  including  the  sphincter,  and  then 
opens  the  abdomen,  draws  the  bowel  upward  until  taut,  and  anchors 
it  to  the  anterior  abdominal  parietes  (sigmoidopexy). 

Coccygeal  deformity,  where  the  bowel  projected  forward,  induced 
obstinate  diarrhea  in  3  of  the  author's  cases;  in  each  instance  nor- 
mal evacuations  followed  excision  of  the  offending  segments. 


CHAPTER   XLVI 

POSTOPERATIVE  DIARRHEA 

It  is  only  within  the  present  decade  that  postoperative  diarrheas 
have  received  any  attention,  and  up  to  the  present  only  a  few  good 
articles  have  appeared  upon  this  subject,  and  while  these  have  in  a 
measure  cleared  up  many  points  concerning  this  most  interesting  type 
of  loose  movements,  the  subject  still  requires  much  elucidation  before 
it  will  receive  the  attention  which  its  importance  deserves. 

Errors  in  diet  are  often  responsible  for  frequent  loose  movements 
following  surgical  inter\^ention  for  the  relief  of  a  variety  of  conditions, 
particularly  those  affecting  the  gastro-intestinal  tract;  later,  after  the 
patient  has  been  on  a  strict  diet,  he  is  permitted  to  eat  whatever  he 
chooses. 

ETIOLOGY  AND  PATHOLOGY 

It  is  a  well-known  fact  that  a  considerable  number  of  patients, 
laparotomized  for  various  purposes,  suffer  from  constipation  and 
occasionally  from  coprostasis,  where  fecal  masses  assume  a  putty  con- 
sistence and  size  sufhcient  to  obstruct  the  bowel  or  form  numerous  hard 
irregular  or  round  scybala,  which  may  be  scattered  along  the  gut  or  col- 
lected en  masse,  forming  a  tumor  of  considerable  proportions.  When 
such  accumulations  are  not  promptK"  dissolved  or  dislodged  by  medica- 
tion, enemata,  the  finger,  or  instruments,  they  sooner  or  later  produce 
a  stercoral  diarrhea  that  is  extremely  difficult  to  correct.  This  condi- 
tion may  occur  shortly  following  an  operation  while  the  patient  is  on 
a  strictly  milk  diet,  or  later  when  a  regular  or  one  of  more  generous 
proportions  is  allowed,  particularly  in  the  absence  of  daily  laxatives, 
and  where  the  attendant,  for  one  reason  or  another,  ties  up  the  patient's 
bowels  for  several  days.  Recent  accumulations  of. the  above  types 
may  induce  diarrhea  through  obstructing  the  gut,  as  would  a  cancer  or 
other  tumor,  direct  irritation  to  the  bowel,  by  setting  up  a  localized 
catarrh,  favoring  the  retention  of  putrefying  material  and  the  multi- 
plication of  the  normal  intestinal  pathogenic  bacteria  and  their  toxins 
which  lead  to  increased  peristalsis,  glandular  secretion,  and  diarrhea 
owing  to  their  influence  upon  the  local  and  general  mechanism. 

In  postoperative  chronic  coprostasis  the  movements  are  more  per- 
sistent, water\%  have  a  very  foul  odor,  may  contain  pus,  blood,  and 
mucus,  either  alone  or  admixed,  and  the  patient  suffers  from  insomnia, 
malaise,  dirty  complexion,  high  temperature,  furred  tongue,  abdominal 
tenderness,  and  many  of  the  more  common  manifestations  of  typhoid 
fever,  for  which  the  condition  has  frequently  been  mistaken.  Here 
the  diarrhea  is  incited  in  the  above-mentioned  ways,  together  with 
irritation  and  trauma  to  the  exposed  nerve-endings  within  the  stercoral 

519 


520  POSTOPER-VTIVE    DIARRHEA 

ulcers,  which  soon  form  in  the  vicinity  of  impacted  masses  through 
pressure,  necrosis,  or  infection. 

The  most  exhausting  and  fatal  types  of  postoperative  diarrheas 
are  those  which  follow  gastric  operations  (gastro-enterostomy,  gastric 
resection,  and  pyloroplasty),  forms  frequently  encountered  in  this 
class  of  work,  but  thus  far  unsatisfactorily  accounted  for,  and  are  mys- 
terious in  that  they  arise  during  the  stage  of  convalescence  and  often 
continue  in  spite  of  the  treatment  until  the  death  of  the  patient  a  few 
days  later.  These  conditions  are  peculiar  in  that  they  occur  in  what 
are  believed  favorable  cases,  where  the  patient  has  improved  until  he 
is  considered  out  of  danger  from  the  operation  and  is  permitted  to  pass 
from  a  restricted  to  a  more  liberal  diet,  following  correction  of  the 
original  condition  which  was  responsible  for  fermentation,  putrefac- 
tion, and  other  disturbances. 

In  studying  this  subject  it  is  necessary  to  take  into  consideration 
that  the  condition  for  which  the  operation  is  performed  has,  in  most 
instances,  previously  reduced  the  patient  to  a  most  deplorable  state, 
there  is  emaciation,  impoverished  circulation,  abnormal  secretions  and 
excretions,  and  a  general  derangement  of  metabolism,  if  it  has  not 
already  caused  a  catarrhal  or  other  diseased  condition  of  the  gastro- 
intestinal tract. 

Surgeons  differ  as  to  the  cause  of  the  exhausting  and  frequent 
evacuations  which  take  place  following  operation  in  these  cases,  and 
it  has  been  attributed  to  (a)  intoxication  dyspepsia  incident  to 
putrefactive  fermentation;  {h)  irritative  effect  of  chloroform  upon 
the  gastro-intestinal  tract;  (c)  want  of  neutralization  of  the  gastric 
secretion  (hydrochloric  acid)  by  the  bile  and  pancreatic  juices,  owing 
to  its  being  deposited  in  the  intestine  below  through  an  artificial 
opening;  and  {d)  irritation  to  the  mucosa  by  the  residue  of  an 
abundant  varied  diet  following  strict  abstinence  from  solid  food.  In 
these  subjects,  owing  to  the  depleted  condition  of  the  patient, 
which  minimizes  the  amount  of  alkaline  fluid  secreted  and  the  lack 
of  direct  stimulation  of  biliar^^  and  pancreatic  secretions  which  would 
normally  ensue  if  the  gastric  acid  passed  directly  from  the  stomach 
to  the  intestine  below,  and  to  the  fact  that  after  operation  the  gastric 
juice  does  not  have  to  pass  through  the  duodenal  reservoir  or  trap 
designed  to  retain  the  alkaline  fluid  until  a  considerable  amount  is 
collected,  not  enough  of  alkali  reaches  the  small  intestine  to  meet  the 
demands  made  upon  it  by  the  decomposing  products  within,  which,  as  a 
result,  sets  up  an  irritative  diarrhea.  Under  this  condition.  Heile  main- 
tains that  the  alkali,  which  under  normal  circumstances  would  be 
absorbed  by  the  colon,  is  lost  because  it  undergoes  combustion  into 
alkaline  carbonates  and  is  excreted,  with  the  result  that  aceto-acetic 
acid,  acetone,  etc.,  appear  in  the  urine  and  the  patient  develops  entero- 
genic  coma,  resembling  that  of  diabetes,  which  so  frequently  compli- 
cates this  variety  of  loose  movements. 

Postoperative  gastric  diarrhea  may  follow  any  operation  upon  the 
stomach,  but  most  frequently  complicates  gastro-enterostomy,  gastric 


ETIOLOGY    AND    PATHOLOGY  52 1 

resection,  and  pyloroplasty.  This  diarrhea  occurs  more  often  and 
is  more  aggravated  when  the  operation  is  performed  for  the  relief  of 
cancerous  than  benign  obstruction,  when  the  lesion  is  at  the  pylorus 
than  elsewhere,  and  when  a  gastro-enterostomy  is  made  with  a  long 
intestinal  loop  than  a  short  one.  Dangerous  diarrhea  rarely  follows 
gastro-enterostomy  performed  for  the  relief  of  benign  affections,  par- 
ticularly when  the  opening  is  made  within  12  inches  of  the  duodeno- 
jejunal angle.  This  condition  is  apt  to  follow  operation  ior  whatever 
purpose  when  the  anastomosis  is  made  low  down  in  the  jejunum,  be- 
cause the  gastric  secretions  lose  the  influence  of  the  bile  and  pancreatic 
fluids  and  imperfect  intestinal  indigestion  naturally  ensues. 

Auschiitz  believes  that  certain  individuals  show  a  predisposition 
to  postoperative  diarrhea.  Decrepit  subjects  and  those  suffering 
from  tubercular  lesions  independent  of  bowel  trouble  are  more  prone 
to  it.  Carle  and  P'antino  attribute  the  loose  movements  to  chloro- 
form, which  causes  putrefactive  fermentation  and  gastro-intestinal 
catarrh,  but  Auschiitz  has  disproved  this  by  substituting  ether  for 
chloroform.  He  found  that  catarrh  occurred  after  one  as  often  as  the 
other,  and  says  that  it  would  be  remarkable  for  the  effect  of  chloro- 
form to  manifest  itself  from  the  seventh  to  the  tenth  day  or  later, 
when  the  diarrhea  occurs  in  these  cases.  This  authority  does  not 
believe  that  gastric  postoperative  diarrhea  is  of  very  common  occur- 
rence, as  he  noticed  diarrhea  only  30  times  in  500  operations,  including 
gastro-enterostomies,  resections,  and  pyloroplasties. 

Distressing  diarrhea  may  occur  in  connection  with  peritonitis, 
sepsis,  the  formation  of  abscesses  or  sloughing  of  the  transverse  colon 
subsequent  to  gastric  or  other  abdominal  operations,  and,  according  to 
Auschiitz,  following  nutrient  enemata  when  the  rectal  mucosa  is  in- 
flamed. Again,  a  pre-existing  intestinal  catarrh  may  be  incited  to 
renewed  activity  by  the  operative  interference  and  lead  to  increased 
frequency  of  the  movements.  Consequently,  it  is  important  to  deter- 
mine if  the  bowel  is  healthy  or  the  patient  is  already  afflicted  with 
diarrhea  before  deciding  upon  the  more  serious  gastro-intestinal  opera- 
tions; otherwise,  on  account  of  the  patient's  weakened  condition,  post- 
operative diarrhea  may  ensue  and  he  will  soon  die  from  exhaustion. 

There  is  also  a  variety  of  loose  movements  which  sometimes  follow 
the  establishment  of  an  artificial  anus,  intestinal  exclusion,  or  resection 
made  for  the  purpose  of  relieving  malignant  or  other  forms  of  intestinal 
obstruction,  or  giving  rest  to  a  diseased  segment  of  bowel. 

After  colostomy  the  frequent  evacuations  are  involuntary,  and  take 
place  owing  to  a  lack  of  sphincteric  control  as  a  result  of  increased 
peristalsis  consequent  upon  irritation  to  the  exposed  nerve-endings  in 
the  edges  of  the  gut  and  wound. 

Short-circuiting  or  exclusion,  done  to  eliminate  all  or  a  considerable 
portion  of  the  colon,  makes  it  necessary  to  join  the  proximal  end  of  the 
ileum  to  the  sigmoid  flexure  and  rectum.  After  these  operations  the 
patient  has  from  five  to  ten  fluid  or  semisolid  evacuations  daily  for 
several  weeks,  due  to  the  fact  that  there  is  no  reservoir  in  which  the 


522  POSTOPERATIVE    DIARRHEA 

feces  may  collect  and  remain  until  their  watery  constituents  have  been 
absorbed;  consequently,  they  are  almost  continually  poured  into  the 
rectum,  to  be  evacuated  before  they  become  solid.  This  type  of 
surgical  diarrhea  has,  in  the  author's  experience,  invariably  improved 
without  treatment  week  by  week,  until  at  the  end  of  about  three  months 
the  stools  become  normal  as  regards  frequency  and  consistency  on 
account  of  the  ileum  acting  the  part  of  the  colon. 

Excision  of  a  short  or  long  piece  of  the  healthy  small  intestine  in 
dogs  is  usually  followed  by  a  diarrhea  which  persists  permanently  or  for 
a  considerable  time,  which  would  indicate  that  the  entire  small  gut  is 
necessary  to  the  metabolic  process,  while  similar  operations  upon  the 
colon  produce  but  a  slight  if  any  diarrhea,  and  when  this  occurs  it 
is  probably  due  to  the  ensuing  trauma.  In  human  beings  the  operation 
is  usually  performed  for  the  relief  of  serious  organic  lesions  of  the  gut. 
Hence  it  is  not  surprising  that  the  evacuations  should  be  abnormally 
frequent  after  resection,  owing  to  the  irritable  state  of  the  bowel,  nor 
when  several  feet  of  the  small  intestine  or  a  considerable  portion  of  the 
colon  is  excised,  because  in  the  former  the  intestinal  juices  are  prevented 
from  performing  their  full  function,  and  in  the  latter  because  there  is 
no  opportunity  for  the  watery  contents  of  the  feces  to  remain  in  the 
colon  until  absorption  has  taken  place.  In  some  instances  the  diar- 
rheal disturbance  is  of  short  duration,  the  bowel  becoming  used  to  the 
new  state  of  affairs,  while  in  others  it  becomes  chronic.  Occasionally, 
loose  movements  following  resection  are  due  to  obstruction  resulting 
from  a  stricture  at  the  site  of  anastomosis. 

In  aggravated  cases  of  acute  obstruction,  where  the  bowel  has 
become  distended  with  accumulated  irritating  gases,  putrefactive 
material,  bacteria,  and  toxins,  the  patient  frequently  suffers  severely 
or  dies  from  the  absorption  of  septic  material  or  exhausting  diarrhea 
caused  by  the  effect  of  the  toxic  substances  from  above  being  poured 
into  the  healthy  bowel  below,  even  though  the  obstruction  has  been 
successfully  relieved  by  operation. 

Finally,  annoying  or  dangerous  postoperative  diarrhea  may  com- 
plicate operations  performed  for  the  relief  of  exophthalmic  goiter, 
certain  affections  of  the  liver  or  pancreas  and  their  ducts,  and  may  follow 
serious  surgical  intervention  for  any  purpose  in  patients  who  suffer 
from  nephritis,  diabetes,  or  other  organic  or  constitutional  disease  when 
the  resistance  of  the  patient  is  at  a  low  ebb  or  is  already  afflicted  with 
an  inflammatory  or  ulcerative  intestinal  disease. 

SYMPTOMS  AND  DIAGNOSIS 
The  symptomatology  of  postoperative  gastric  diarrhea  is  not  very 
clear,  varies  considerably  in  different  cases;  the  suffering  is  more 
frequent  and  persistent  in  individuals  afflicted  with  cancer  than  other 
gastric  lesions.  The  most  dangerous  manifestation  is  stagnation  of 
the  stomach  contents,  which  may  prevail  cither  before  or  after  opera- 
tion. Ordinarily  the  patient  goes  along  very  well  for  several  days 
following  surgical  intervention,  and  then,  while  under  favorable  circum- 


TREAT.MKXT 


0-^.5 


Stances — viz.,  comfortable  surroundings,  rest  in  bed,  and  a  controlled 
diet — stagnation  and  diarrhea  suddenly  super\'ene,  and  the  latter  is 
difficult  or  impossible  to  control  by  antidiarrheal  remedies.  In  mild 
cases  the  stomeich  condition  improves  and  the  diarrhea  abates  in  one  or 
two  weeks  without  greatly  exhausting  the  patient.  Postoperative 
diarrhea  is  always  most  severe  and  often  fatal  when  the  frequent  evacu- 
ati(jns  occur  late  (tenth  to  fifteenth  day)  and  following  marked  stag- 
nation and  vomiting  of  offensive  blackish  material.  Some  of  these 
patients  first  become  delirious,  then  unconscious,  and  finally  pass  into 
a  state  resembling  diabetic  coma. 

In  this  type  of  cases  the  evacuations  are  very  frequent,  fluid,  of  a 
reddish  tint,  contain  shreds  of  mucus,  have  a  foul  odor,  and  near  the 
end  in  fatal  cases  the  feces  continually  dribble  through  the  anus. 
A  case  of  this  kind  has  been  reported  by  Auschiitz  where  the  small  in- 
testine, large  bowel,  and  rectum  contained  numerous  deep-seated  ulcers, 
while  the  mucosa  of  the  cecum  appeared  normal  and  that  of  the  colon 
markedly  swollen. 

TREATMENT 

Following  abdominal  and  operations  mentioned,  when  diarrhea 
ensues  as  the  result  of  the  patient  eating  too  much,  at  irregular  hours, 
or  indigestible  food,  the  treatment  consists  in  correcting  errors  of 
diet,  substituting  suitable  food,  and  in  prescribing  an  opiate,  anti- 
septic, or  astringent  to  afford  temporary  relief.  In  these  cases,  be- 
cause of  an  obstruction  or  other  lesion,  the  patient  has,  for  a  consider- 
al>le  time,  been  left  upon  a  fluid  or  ver\'  restricted  diet  before  and  suffers 
from  diarrhea  after  operation,  the  latter  is  usually  caused  by  resuming 
a  regular  diet  and  consuming  a  greater  amount  of  food  than  the  gastro- 
intestinal tract  has  been  accustomed  to  taking  care  of,  with  the  result 
that  indigestion  ensues,  the  gut  is  irritated,  or  a  catarrhal  condition  is 
excited.  The  treatment  is  obvious  in  these  cases,  and  consists  in 
controlling  the  diet  and  slowly  graduating  it  up  to  the  normal,  and  the 
administration  of  suitable  remedies  to  control  the  loose  movements 
during  the  attack. 

In  coprostasis  the  inciting  factor  of  the  diarrhea  is  the  impacted 
fecal  masses  and  backed-up  toxins.  Consequently,  measures  should 
be  instituted  which  will  prevent  the  undue  accumulation  of  feces,  or 
hasten  their  removal  when  they  have  already  collected,  by  attacking 
them  from  abo\'e  and  below,  and  to  this  end  castor  oil  may  be  pre- 
scribed when  scybala  are  present,  or  liberal  doses  (5ij  to  iij — 60.0-90.0) 
of  mineral  or  sweet  oil  to  soften  large  putty-like  masses  and  lubri- 
cate the  intestine.  Meanwhile  frequent  large  (i  to  2  quarts — liters) 
soapsuds  enemata,  containing  oil,  5ij  to  iv  (60.0-120.0),  and  turpen- 
tine, 3ss  to  j  (2.0-4.0),  should  be  deposited  high  up  in  the  colon  to  help 
dissolve  and  dislodge  the  accumulations,  using  massage  to  break  them 
up  between  the  injections.  In  urgent  cases  the  mechanical  breaking 
up  of  the  mass  can  be  materially  hastened  by  the  introduction  of  a  25 
per  cent,  solution  of  the  peroxid  of  hydrogen,  which  has  the  peculiar 
power  of  quickly  penetrating  fecal  masses  and  rapidly  disintegrating 


524  POSTOPERATIVE    DIARRHEA 

them  so  that  they  may  be  washed  out.  Firm  mucus-covered  fecal 
tumors  in  the  sigmoid  flexure  or  rectum,  upon  which  water  and  oil 
have  Httle  effect,  can  be  quickly  broken  up  with  the  finger  or  gouge  and 
evacuated  through  the  proctoscope  or  sigmoidoscope  by  continuous 
irrigation.  Following  their  dislodgment,  olive  oil,  oiv  (120.0),  and 
bismuth  subnitrate,  §ss  (15.0),  should  be  injected  high  into  the  colon 
to  soothe  and  heal  the  inflamed  or  ulcerated  mucosa,  a  therapeutic 
measure  which  affords  the  patient  much  comfort  and  diminishes  the 
frequency  of  the  evacuations. 

Diarrhea  consequent  upon  gastro-enterostomy,  resection,  and  py- 
loroplasty is  impossible  to  relieve  in  aggravated  cases  where  there  is 
profound  stagnation,  but  in  the  less  severe  types  of  loose  movements 
much  can  be  done  to  palliate  the  patient's  suffering  and  control  the 
movements  providing  corrective  measures  are  instituted  early.  \\"hen 
consequent  upon  achylia  gastrica,  acidity  should  be  increased  by  oft- 
repeated  and  liberal  doses  of  dilute  hydrochloric  acid,  but  when  a 
reverse  condition  prevails,  and  there  is  hyperacidity,  bicarbonate  of 
soda,  gr.  xx  to  xl  (1.3-2.6);  magnesium,  gr.  x  to  xxx  (0.60-2.0),  and 
lime-water,  5j  to  ij  (4.0-8.0);  or  powder,  gr.  x  to  xxx  (0.60-2.0), 
should  be  employed  alone  or  in  combination  with  bismuth,  gr.  x  to  xx 
(0.60-1.3);  charcoal,  gr.  x  to  xxx  (0.60-2.0);  or  cerium  oxalate,  gr.  j 
(0.06) ,  three  times  daily,  because  of  their  neutralizing  and  sedative  effect. 

When  there  is  marked  stagnation  with  vomiting  it  may  not  be 
possible  to  save  the  patient,  but  much  can  be  done  for  his  comfort  by 
washing  out  the  stomach  and  intestine  to  free  them  of  their  irritating 
contents,  and  when  this  fails  to  give  relief,  calomel,  strong  laxatives, 
or  castor  oil  may  be  administered  with  the  object  of  expelling  the 
offensive  material. 

Patients  afflicted  with  this  stagnant  type  of  diarrhea  and  some  other 
forms  of  postoperative  diarrhea  may  first  become  delirious  and  then 
pass  into  a  state  resembling  diabetic  coma,  a  condition  which  Heile 
attributes  to  the  body's  loss  of  alkali.  This  condition  has  been  suc- 
cessfully treated  by  him  through  the  administration  of  large  quantities 
of  alkali,  introducing  into  the  body  up  to  5v  (20.0)  of  sodium  citrate 
by  mouth;  a  5  to  10  per  cent,  solution  of  citric  acid  and  sodium  'oicar- 
bonate  by  the  rectum;  and  of  sodium  bicarbonate  up  to  i  per  cent, 
intravenously,  and  symptomatically  treating  the  diarrhea.  He 
claims  that  better  results  are  obtained  from  this  treatment  in  these 
cases  than  in  diabetic  coma,  because  the  loss  of  alkali  here  takes  place 
through  the  bowel,  whereas  in  the  former  it  is  based  upon  pathologic 
changes  of  metabolism. 

Surgical  Treatment.— In  the  surgical  treatment  of  postoperative 
diarrhea  following  gastro-enterostomy,  where  the  opening  has  been 
made  low  in  the  small  intestine,  a  second  operation  may  be  required 
and  a  higher  anastomosis  made  to  relieve  the  condition. 

Peritonitis,  sepsis,  abscess,  and  slotighing  of  the  transverse  colon 
demand  immediate  surgical  attention  and  hot  abdominal  applications, 
colonic  irrigation,  and  measures  to  relieve  pain  and  control  the  move- 


SURGICAL    TRKATMIiNT  525 

nients  arc  not  to  be  relied  upon  except  for  the  purpose  of  relieving  the 
patient's  sufiering  until  the  operation  can  be  performed. 

Where  diarrhea  is  induced  by  the  long-continued  use  of  rectal  ene- 
mata  following  operations  they  should  be  administered  less  frequently, 
and  the  lower  bowel  should  be  bathed  with  a  weak  boric  acid  solution 
or,  preferably,  with  olive  oil  containing  l)ismuth  to  reduce  the  inHamma- 
tion  tmd  irritabilit\'  of  the  mucosa  and  relieve  tenesmus. 

Catarrh  of  the  small  and  large  intestine  is  often  a  complication  of 
postoperative  diarrhea,  having  existed  prior  to,  or  been  caused  by,  sub- 
sequent gastro-intestinal  changes,  and  requires  individual  considera- 
tion along  with  the  symptomatic  treatment  of  the  loose  movements. 

When  diarrhea  is  not  improved  by  lavage  and  restricting  the  diet, 
an  attempt  should  be  made  to  diminish  the  frequency  of  the  evacua- 
tions by  the  administration  of  opium  in  |-gr.  doses  three  or  four  times 
daily,  or  laudanum,  nj  x  to  xv  (0.60-1.0),  may  be  substituted  for  it,  and 
bismuth,  gr.  x  to  xx  (0.60-1 .3) ,  tannalbin  or  ichthalbin,  gr.  x  to  xv  (0.60- 
i.o),  administered  every  four  hours,  will  be  found  useful  adjuncts,  but 
these  reliable  remedies  usually  fail  in  the  most  serious  or  stagnant  cases. 

To  these  therapeutic  measures  should  be  added  bowel  irrigation 
with  solutions  of  ichthyol  (|  to  i  per  cent.),  boric  acid,  2  per  cent., 
permanganate  of  potash,  |  to  i  per  cent.,  or  krameria  and  sodium  bibo- 
rate  in  the  following  proportions,  to  soothe  and  heal  local  inflammatory 
and  ulcerative  lesions  within  the  colon  and  rectum: 

I^     Fl.  ext.  krameria oiv  (120.0); 

Sodii  biboratis oij  (8.0).— M. 

Sig. — One  or  two  tablespoonfuls  in  a  quart  of  warm  water,  and  inject  daily  or  three 
times  weekly,  according  to  indications. 

The  frequent  movements  following  the  formation  of  an  artificial 
anus  can  be  somewhat  reduced  by  encouraging  the  raw  edges  of  the 
abdominal  wound  and  gut  to  heal  by  the  application  of  a  6  per  cent, 
silver  nitrate  solution,  but  after  healing  takes  place,  where  there  is 
incontinence,  they  are  not  controllaljle  except  by  antidiarrheal  or 
constipating  remedies.  This  form  of  diarrhea  is  largely  unnecessary, 
and  can  be  avoided  by  performing  colostomy  according  to  the  author's 
method  elsewhere  described,^  which  gives  the  patient  a  controllable  anus. 

Excepting  the  administration  of  medicines  to  quiet  peristalsis  and 
solidify  the  feces,  keeping  the  patient  quiet,  and  having  him  discard 
indigestible  foods,  nothing  can  be  done  to  control  the  frecjuent  fluid 
evacuations  following  intestinal  exclusion  and  resection,  where  the 
ileum  has  been  joined  to  the  sigmoid  flexure  or  rectum.  Time,  how- 
ever, will  accomplish  what  therapeutic  measures  do  not,  for  in  these 
subjects  the  movements  gradually  become  less  frequent  and  more  firm, 
until  normal  daily  passages  occur  within  from  six  to  fifteen  months. 
The  lower  ileum  gradually  assumes  the  functionating  power  of  the 
colon,  evidence  of  which  has  been  observed  by  the  author  man\-  times, 
and  in  two  instances  the  small  bowel  was  found  greatly  enlarged, 
thickened,  and  possessed  some  of  the  characteristics  of  the  colon. 
1  Gant,  Constipation  and  Intestinal  Obstruction,  ''Diseases  of  Rectum  and  .\nus." 


CHAPTER   XLVII 

MESENTERIC  EMBOLISM  AND    THROMBOSIS   iINTESTI:NAL 
INFARCTION',   DIARRHEA   IN 

ETIOLOGY    AND   PATHOLOGY 

Mesenteric  embolism  or  thrombosis  and  the  resulting  infarct 
are  encountered  most  often  in  individuals  having  an  impaired  circu- 
lation, such  as  endocarditis,  valvular  disease,  cirrhosis  of  the  liver,  or 
atheromatous  degeneration  of  the  vessels,  particularly  of  the  aorta, 
as  a  result  of  lues.  The  superior  or  inferior  mesenteric  vessels  may  be 
affected,  but  in  a  vast  majority  of  cases  it  is  the  former;  embolic 
obstruction  occurs  in  about  3  cases  to  i  of  thrombosis,  and  men  are 
affected  twice  as  often  as  women. 

In  mesenteric  vascular  obstruction,  where  a  large  vessel  is  involved, 
the  condition  of  the  patient  is  rendered  most  serious.  There  is  less 
danger  when  a  branch  is  blocked,  and  the  prognosis  is  still  more  favor- 
able when  a  diminuti^"e  capillarv"  is  occluded.  From  what  has  been 
said  it  may  be  inferred  that  an  infarct  in  one  case  may  be  ver>'  exten- 
sive as  regards  the  mesentery  and  adjacent  segment  of  the  bowel,  and 
insignificant  in  another,  according  to  the  size  and  number  of  vessels 
involved  by  the  obstruction.  In  rare  instances,  where  interference 
with  the  circulation  is  limited  to  a  small  area,  possibly  a  collateral  cir- 
culation may  preserve  the  part,  but  usually  necrosis  of  the  affected 
area  follows  closely  upon  formation  of  the  embolism  or  thrombus. 
When  an  arter\-  is  blocked,  anemia  immediately  ensues  and  gangrene 
quickly  follows,  but  when  a  vein  is  occluded  necrosis  may  occur  more 
slowly,  since  the  part  continues  to  receive  fresh  blood,  which  early 
becomes  impure,  and  is  extravasated  into  the  surrounding  tissue. 
Except  when  quickh-  discovered  and  removed,  and  this  is  unusual,  a 
clot  in  the  superior  mesenteric  artery  (or  'vein)  or  one  of  its  chief 
branches  quickly  leads  to  gangrene  and  the  complete  destruction  of 
one  or  several  lengthy  segments  of  the  gut,  which  may  include  a  por- 
tion of  the  small  bowel,  cecum,  or  ascending  colon,  or  less  frequently 
when  the  inferior  mesenteric  artery  (or  vein)  or  its  offshoots  are  in- 
volved, the  colon,  sigmoid  flexure,  or  rectum  may  become  necrotic  and 
cause  the  patient's  death  unless  he  is  immediately  operated  upon. 
When  distant  branches  of  these  vessels  supplying  the  mucosa  become 
blocked  they  produce  embolic  or  thrombotic  ulcers,  according  to  the 
capillaries  interfered  with.  These  lesions  usually  result  from  the  clot- 
ting of  a  number  of  diminutive  vessels  located  in  the  small  or  large 
intestine,  but  are  encountered  most  often  in  the  jejunum  or  ileum. 
526 


SYMPTOMS    AND    DIAGNOSIS  527 

Thrcjmbosis  is  prone  to  occur  in  indi\uduals  who  suffer  from  a 
chronic  catarrhal,  tubercular,  entamebic,  or  syphilitic  enterocolitis, 
because  of  the  tendency  of  the  disturbing  microbe  to  enter  the  capil- 
laries. 

Symptoms  and  Diagnosis. — Intestinal  embolism,  thrombosis,  and 
infarction  ma\'  be  suspected,  but  are  rarely  diagnosed,  except  by  open- 
ing the  abdomen  and  inspecting  the  gut  and  mesentery,  and  even  then 
have  frequently  been  confused  with  other  bowel  lesions.  Gebhardt  has 
suggested  the  following  diagnostic  rules — viz.:  (i)  There  must  be  a 
source  of  embolism;  (2)  copious  intestinal  hemorrhages  unexplained 
by  organic  disease  of  the  bowel  or  by  portal  obstruction;  (3)  a  rapid 
and  marked  fall  of  the  temperature;  (4)  more  or  less  colicky  abdominal 
pains;  (5)  distention  of  the  abdomen  and  the  accumulation  of  free 
abdominal  fluid;  (6)  the  occurrence  of  embolism  elsewhere,  before 
or  simultaneous  with  obstruction  of  the  mesenteric  vessels,  and  (7) 
the  discovery  of  a  palpable  mass  (mesenteric  hematoma). 

The  manifestations  of  mesenteric  vascular  obstruction  usually  de- 
velop rapidly,  though  occasionally,  in  slowly  forming  thrombi,  they 
may  run  a  subacute  or  chronic  course.  The  disease  is  characterized  at 
times  by  constipation  and  diarrhea,  the  first  being  intractable  in  all 
stages,  owing  to  the  obstruction  present  and  the  early  development  of 
peritonitis,  while  diarrhea  most  often  occurs  in  the  less  acute  cases,  is 
due  to  obstruction,  retained  irritants,  scybala,  toxins,  or  embolic  ulcers. 

Blocking  of  the  mesenteric  vessels  is  early  characterized  by  intes- 
tinal hemorrhages  or  evidences  of  obstruction,  and  serious  manifesta- 
tions rapidly  follow  each  other.  Very  often  there  is  a  sudden  fall  of 
temperature,  accelerated  pulse,  localized  tenderness,  circumscribed 
or  general  peritonitis,  colicky  pains,  nausea,  and  vomiting  (which  may 
or  may  not  have  fecal  characteristics  depending  on  whether  or  not  there 
is  obstruction).  Hemorrhages,  slight  or  profuse,  always  take  place, 
and  the  blood  may  be  evacuated  immediately  or  be  retained,  showing 
as  melena  or  dark,  blackish-brown,  or  tarry  movements  shortly  or 
several  days  following.  Gebhardt  maintains  that  in  embolism  of  the 
inferior  mesenteric  bright  red  blood  is  evacuated,  and,  on  the  other 
hand,  when  the  superior  mesenteric  is  involved  the  movements  are 
dark  and  tar-like  in  consistence,  but  has  offered  no  convincing  reason 
as  to  why  this  is  so.  The  author  believes  that  the  character  of  the 
blood  voided  has  no  relation  to  the  disease  of  these  vessels,  but  that  it 
depends  upon  the  degree  of  peristalsis  present  and  the  time  it  is 
retained,  being  fresh  during  or  shortly  following  the  hemorrhage  and 
tar-like  when  it  is  not  evacuated  until  several  hours  or  days  afterward. 

Diarrhea  here  may  be  moderate  and  the  stools  composed  almost 
wholly  of  blood,  or  they  may  be  very  frequent,  watery  and  exhausting, 
and  contain  little  if  any  blood.  Again,  the  loose  movements  resemble 
those  of  acute  gastro-enteritis  or  toxic  poisoning  and  usually  the  patient 
suffers  considerable  abdominal  pain,  but  occasionally  this  symptom  is 
absent.  Sometimes,  in  arldition  to  localized  tenderness  and  pain,  a 
fair-sized  tumor  resulting  from  the  infarction  and  swelling  can  be  felt 


528        MESENTERIC    EMBOLISM    AND    THROMBOSIS,    DIARRHEA    IX 

in  the  region  of  the  clot,  but  such  an  enlargement  is  usually  mistaken 
either  for  a  fecal  impaction,  carcinoma,  or  invagination.  In  fatal  cases 
the  patient  dies  from  obstruction  or  peritonitis. 

Prognosis. — Where  emboli  or  thrombi  block  diminutive  vessels 
in  the  mucosa,  nothing  more  serious  than  the  formation  of  ulcers, 
which  heal  later,  occur,  but  when  larger  vessels  supplying  an  individual 
or  several  segments  of  the  gut  are  obstructed  and  collateral  circulation 
to  the  affected  mesentery  and  bowel  is  not  forthwith  established,  or  the 
defect  corrected  by  operation,  gangrene  and  obstruction  rapidly  super- 
vene and  cause  death  within  a  few  hours  or,  at  most,  days.  A  few  spon- 
taneous recoveries  have  been  reported. 

The  treatment  of  embolic  and  thrombotic  diarrhea  is  ver\'  unsatis- 
factory, and  must  necessarily  be  symptomatic  or  operative.  It  is  claimed 
that  increased  pressure  of  the  portal  system  is  largely  responsible  for  the 
hemorrhage;  consequently,  it  is  advisable  to  stimulate  the  heart  action 
with  digitalis,  str^'chnin,  or  nitroglycerin,  or  the  pressure  may  be  re- 
lieved by  tapping  a  vein  and  thereby  removing  tension.  Recently  a 
number  of  these  sufferers  have  been  relieved  by  resection  and  anas- 
tomosis, or  b\-  attaching  the  affected  gut  to  the  skin  and  forming  an 
artificial  opening,  the  continuity  of  the  gut  being  re-established  later. 
Most  of  these  operations,  however,  are  fatal,  as  is  shown  in  the  statis- 
tics of  47  operated  cases  collected  by  Jackson,  Porter,  and  Quimby, 
wherein  the  mortality  was  92  per  cent. 


CHAPTER   XLVIII 
FORMULARY 

To  meet  the  needs  of  the  busy  practitioner  and  provide  for  exi- 
gencies that  may  arise  in  diarrheal,  inflammatory,  and  parasitic  affec- 
tions of  the  gastro-intestinal  tract  the  author  has  compiled  the  fol- 
lowing suggestions,  rules,  and  prescriptions. 

The  therapeutic  measures  herein  suggested  are  more  useful  in  the 
symptomatic  than  in  the  curative  treatment  of  these  affections,  and 
are  intended  to  carry  the  patient  over  sudden  crises  or  until  a  more 
complete  and  rational  treatment  can  be  instituted. 

Patients  afflicted  with  diarrhea,  intestinal  catarrh,  or  parasitic 
diseases  should  (a)  dress  warmly  in  winter  and  coolly  in  summer;  (b) 
restrict  the  diet  to  exclude  foods  known  to  disagree  with  them,  refrain 
from  drinking  alcoholic  ice-cold  drinks,  strong  tea  and  coffee,  or  eat- 
ing ice-cream,  articles  of  diet  which  leave  a  large  irritating  residue — 
raw  fruits,  shell-fish — and  should  live  chiefly  upon  milk,  soups,  eggs, 
cream,  and  butter;  (c)  rest  quietly  in  bed  during  acute  crises  and  live 
in  the  fesh  air  and  indulge  in  moderate  exercise  between  the  attacks; 
(d)  take  a  nerve  and  blood  tonic  when  indicated;  (e)  do  everything 
possible  to  add  to  the  body  fat;  (/)  avoid  excitement,  business  cares, 
and  mental  worries;  (g)  not  employ  opiates  except  when  imperative; 
{h)  irrigate  the  colon  three  times  weekly  with  a  normal  saline  or  one  of 
the  medicated  solutions  given  below  when  the  mucosa  is  highly  in- 
flamed or  ulcerated,  and  (i)  reinforce  the  above  methods  of  treatment 
with  astringents,  antiseptics,  bactericidal,  or  other  medical  agents 
when  necessary. 

On  account  of  the  dissimilarity  in  which  prescriptions  of  the  differ- 
ent authorities  quoted  have  been  written,  the  author  has  taken  the 
liberty  of  slightly  changing  some  of  them  so  that  all  will  appear  har- 
monious, but  their  dosage  and  method  of  administration  have  rarely 
been  altered. 

To  make  the  formula"  more  useful  in  case  a  prescription  is  needed 
in  a  hurry  the  author  has  classified  them  as  far  as  practicable: 

Intestinal  Catarrh  Caused  by  a  Cold: 

^     Saloli 3  j  (4-0) ; 

Creosoti gr.  xlv  (3.0) ; 

Bismuthi  salicylatis 5j  (4-o)- — ^I- 

Pone  in  capsulas  No.  xx. 
Si<^. — One  capsule  every  three  hours.     Add  opium  or  phenacetin  when  pain  is  trouble- 
some. 

(Hill.) 

34  '  529 


530  FORMULARY 

Fermentative  Dyspepsia  and  Diarrhea: 

^     Creosoti  purificatis HE  xij  (0.75); 

Alcoholis  diluti oiiss  (75.0) ; 

Ammonii  benzoatis 5ij  (8.0) ; 

Glycerini  purificatis O^j  (24.0); 

Infusi  caryophylli q.  s.  ad  ovj  (180.0). — M. 

Sig. — Tablespoonful  in  water  two  or  three  times  a  day  between  meals. 

{Richardson.) 

To  Check  Peristalsis  in  Acute  Enteritis  after  the  Bouel  Has  Been  Completely  Emptied: 

I^     Bismuthi  subcarbonatis gr-  x  (0.60) ; 

Sodii  bicarbonatis gr.  x  (0.60) ; 

Tincturae  opii njj  x  (0.60) ; 

JMucilaginis  tragacanthae njj  xv  (i.o); 

Aquae  distillata; q.  s.  ad  5]  (30-0). — M. 

Sig. — Two  tablespoonfuls  every  four  hours. 

(Nothnagel  Clinic.) 

Subacute  Catarrhal  Enteritis: 

I\f     Spiritus  camphorse §  j  (30.0) ; 

Acidi  sulphurici  diluti oss  (15.0); 

Tincturas  opii  deodoratae §  j  (30.0); 

Tincturae  capsici oss  (15.0); 

Spiritus  chloroformi §ss  (15.0); 

Spiritus  vini  gallici q.  s.  ad  §vj  (180.0). — M. 

Sig. — One  or  two  teaspoonfuls.  well  diluted,  ever>'  three  or  four  hours. 

(Scott.) 

Acute  Intestinal  Catarrh: 

I^     Bismuthi  subnitratis 3iss  (6.0); 

Pulveris  cretae gr.  xlv  (3.0) ; 

Codeine  phosphatis gr.  iss  (0.09); 

Elaeosaccharis  menthae  piperitae gr.  Ixxv  (5.0). — yi. 

Fiant  chartulae  No.  x. 
Sig. — One  powder  three  or  four  times  daily. 

(Einhorn.) 

Co  prostatic  Diarrhea: 

When  fecal  masses  and  scybala  collect  in  the  colon,  sigmoid  flex- 
ure, or  rectum  and  cannot  be  gotten  rid  of  by  cathartics  and  enemata: 

I^     Hydrogenii  dioxidi Oss  (250.0). 

Sig. — Injected  into  the  bowel  will  cause  their  disorganization. 

Diarrhea  Induced  by  Catarrhal  Colo  proctitis: 

I^     Acidi  tannici oss  (15.0); 

Hydrargyri  chloridi  mitis oiiss  (10. o); 

Zinci  stearatis  1  __-../,      s      ,, 

T^  1       •    ,   ,       > aa  51J  (60.0). — Al. 

Fulvens  talc     J  yj  j  \        / 

Fiant  pul\-eris. 
Sig. — Insufflate  the  sigmoid  flexure  through  the  sigmoidoscope  three  times  weekly. 

This   remedy   is   helpful    independently   or   in   combination   with 
remedies  otherwise  administered. 

Rosenberg's  Powder: 

I^     Olci  thymi O  j  (4-o) ; 

Acidi  tannici oss  (15.0); 

Magnesii  carbonatis §iiiss  (loo.o). — M. 

Sig. — Insufflate  the  bowel  as  often  as  required. 


FORMULARY  53 1 

Diarrhea  of  Exophthalmic  Goiter: 

^    Extract!  digitalis gr.  iiss  (0.15); 

Extract!  ergotse 3ss  (2.0J ; 

Strychnine  sulphatis gr.  ss  (0.03) ; 

Ferri  arsenitis gr.  iiss  (0.15). — M. 

Pone  in  capsulas  No.  xxv. 
Sig. — One  capsule  three  times  daily  after  meals. 

{Gant.) 

Catarrhal  Diarrhea  n-ith  Nausea  and  Vomiting: 

I^     Hydrargyri  chloridi  mitis gr.  i  (0.02); 

Sodii  bicarbonatis gr.  iiss  (0.15); 

Sacchari  lactis gr.  uss  (0.15J. — ^I. 

Sig. — Every  hour  or  two  on  tongue. 

(Gant.) 

Mucous  Diarrhea: 

I^     Argenti  nitratis gr.  ij  (0.12); 

Extracti  hyoscyami gr.  v  (0.30). — ]M. 

Fiant  pilulae  Xo.  x. 
Sig.— One  pill  three  times  daily. 

(Hare.) 

Diarrhea  with  Colic: 

R     Camphora;  "I  _-         •      /        , 

Capsici        } ^^  gr.iss(o.09); 

Zingiberis gr.  ij  (o.i 2) ; 

Sacchari  lactis gr.  xv  (i.o). — M. 

Fiant  pilulae  No.  xii. 
Sig. — One  or  more  pills  at  two-hour  inter\'als  according  to  indications. 

(Gant.) 

Choleriform  Diarrhea: 

I^     xEtheris  acetici oU  (8.0); 

Olei  cajupuli njixv  (i.o); 

Tincturaj  opii 5 j  (4-o)- — M. 

Sig. — Ten  or  15  drops  ever>'  two  hours  on  a  lump  of  sugar. 

(Beasley.) 

Bilious  Diarrhea: 

I^     Hydrarg\-ri  chloridi  mitis gr.  j  (0.06) ; 

Sodii  bicarbonatis gr.  x\'  (1.0) ; 

Pulveris  opii gr-  i]  (0.12). — M. 

Fiant  chartula:  No.  viii. 
Sig. — One  every  two  or  three  hours  until  eight  powders  are  used,  followed  by  large 
doses  of  bismuth  and  pepsin. 

(Scott.) 

Nervous  Diarrheas: 

^     Str>-chninae  sulphatis gr.  ss  (0.03); 

Acidi  sulphuric!  aromatic! 5v  (20.0); 

Aqua;  hamamelidis q.  s.  ad  ^iv  (120.0). — M. 

Fiant  solutio. 

Sig. — .\  teaspoonful  in  water  ever}'  three  hours. 

(Cant.) 

^     Tincturae  belladonnas OSS  (2.0) ; 

Kali!  bromid! Siiss  (lo.o); 

Aqua;  distiUatae q.  s.  ad  oiv  (120.0). — M. 

Sig. — A  tablespoonful  three  or  four  times  dailv. 

(Gant.) 


532  FORMULARY 

Nervous  Diarrheas: 

I^    Liquoris  potassii  arsenitis  \  --   -■■  /q    >,      -»c 

Aqua;  amjgdala;  amara    / ^^  ^^J  {.b.o).—M. 

Sig. — Four  drops  three  times  dailj-  after  meals.  Increase  the  dose  bj'  i  drop  every 
second  day  until  20  are  taken;  then  reduce  the  dose  in  the  same  way  down  to  4  drops. 
At  bedtime  administer  effervescent  bromid  salt  of  Sandow  to  encourage  sleep. 

(Charcot.) 

Acute  Diarrhea: 

B^    Olei  ricini gr.  xxiv  (i  .50) ; 

Spiritus  chloroform! oiss  (6.0) ; 

]Morphinae  hydrochloratis gr.  j  (0.06) ; 

Pulveris  acaciae 3iiss  (lo.o); 

S^'rupi  simplicis 3ss  (15.0); 

Aquae  distillatae q.  s.  ad  5i^'  (120.0). — M. 

Sig. — A  dessertspoonful  everj-  hour  and  a  half  for  an  adult. 

iVoung.) 

Acute  Diarrhea  li'ith  Burning  and  Straining: 

J\     Tincturae  opii  deodorati ttj  xij  (0.75); 

Liquoris  potassii  citratis Siiss  (75.0). — M. 

Sig. — Teaspoonful  every  hour  until  relieved. 

(Gant.) 

Diarrhea  Accompanied  by  Burning  in  the  Bowel: 

^     Orthoformi oij  (8.0) ; 

Bismuthi  subnitratis oiss  (45.0); 

Olei  oUvae q.  s.  ad  Oj  (500.0). — M. 

Sig. — Shake  weU.     Warm  and  inject  6  ounces  into  the  colon  after  an  evacuation. 

(Gant.) 

Diarrhea  Due  to  Coprostasis  or  Foreign  Bodies: 

I^     Tincturje  opii ttjx  (0.60) ; 

Spiritus  ammoniae njjxxx  (2.0); 

Spiritus  menths  piperitae npxx'  (i.o); 

Tincturae  catechu 5  j  (4-o) ; 

Aquse  distillatae q.  s.  ad  5  j  (30.0). — M. 

Sig. — Administer  every  three  or  four  hours  following  a  dose  of  castor  oil. 

{Leonard  Williams.) 

Diarrhea  Mixture: 

I^    Tincturae  lavandulae  compositae oi^'  (120.0); 

Sacchari oss  (15.0); 

Aquae  camphorae Oj  (500.0). — ^I. 

Sig. — A  tablespoonful  every  three  hours,  for  diarrhea. 

(Parrish.) 

Diarrhea  Due  to  Indigestion: 

^     Extracti  cannabis  indicae  fluidi ngj  (0.06) ; 

Creosoti gr.  v  (0.30) ; 

Syrupi  acacias q.  s.  ad  oiij  (90-0). — M. 

Sig. — A  teaspoonful  before  meals. 

(Germain  Lee.) 

Dyspeptic  Diarrhea  with  Xausea  or  Vomiting: 

I^     Cerii  oxalatis 3ij  (8.0) ; 

Bismuthi  subnitratis oiiss  (lo.o) ; 

Spiritus  chloroformi 3iss  (6.0); 

Liquoris  calcis  I  __    «..  /,      ^      .., 

r.   '     •  •      - aa  qu  (60.0). — M. 

Syrupi  acacire   1  kj  j  \        ^ 

Sig. — Dessertspoonful  in  water  when  necessary. 

(Gant.) 


FORMULARY  533 

Fermentative  Dyspeptic  Diarrliea: 

I^     Phenolis  litiuefacli gr.  v  (0.30); 

Syrupi  acuciie         I  .__.,,,, 

.  ■  •  ,  aa  Siss  (4.i;.o). — M. 

Aqua;  cinnamomi  )  ^       v^:)-'-';-     ^''^• 

Sig. — One  teaspoonful  before  meals. 

{Gant.) 

Irritative  Diarrhea  of  Adults  with  Cramps: 

'Bf.     Pulveris  rhei 3  iss  (6.0) ; 

Sodii  bicarbonalis 3ij  (8.0); 

Spiritus  ammoni;^  aromatici 3iij  (12.0); 

Spiritus  myrisliLiL' 5vj  (24.0); 

Infusi  caryophylli q.  s.  ad  5viij  (240.0). — M. 

Sig. — A  half  to  a  tablespoonful  three  or  four  times  a  day. 

(Shoemaker.) 

Tubercular  Diarrhea: 

I^     Tinctura;  krameria; 3v  (20.0); 

Tinctune  opii ttjI  (3.50) ; 

Misturaj  cretie q.  s.  ad  §vj  (180.0). — M. 

Sig. — Tablespoonful  every  four  hours. 

[Gant.) 

^,     Methylthioninffi  hydrochlorici  (Merck) gr.  iiss  (0.15); 

Sacchari  lactis gr.  x.xij  (i.so).^M. 

Sig. — In  wafer  or  cajjsule,  one  each  day. 

{Gant.) 

Diarrhea  Accompanied  by  Intestinal  Soreness  and  Burning: 

1^     Acidi  sulphurici  aromatici 3iss  (6.0); 

Spiritus  chloroformi 5ij  (8.0); 

Tinctura;  opii  camphorata; §ij  (60.0); 

Syrupi  zinziberis q.  s.  ad  5iv  (120.0). — M. 

Sig. — Dessertspoonful  in  water  every  two  hours. 

{Hare.) 

Serous  or  Watery  Diarrhea: 

'Bf.     Tinctura;  kino 5j  (30-0); 

Tincture  gamberis  compositie 3vj  (24.0); 

Misturae  creta; giiiss  (105.0); 

Aqua;  cinnamomi q.  s.  ad  %w]  (180.0). — M. 

Sig. — Shake  and  take  a  tablespoonful  every  three  hours. 

{Gant.) 

Diarrhea  in  Typhoid  Fever  with  Imminent  Hemorrhage  or  Peritonitis: 

J\     Argenti  nitratis gr.  ij  (0.12); 

Tinctura;  opii 3ij  (8.0); 

IMucilaginis  acacia' q.  s.  ad  oij  (60.0). — M. 

Sig. — A  teaspoonful  three  or  four  times  daily. 

{William  Pepper.) 

Diarrhea  in  Typhoid  Fever  (Lead  and  Opium  Pill) : 

I^     Plumbi  acctas gr.  xij  (0.75); 

Pulveris  opii gr-  iij  (0.18) ; 

Camphora; gr-  xij  (0.75). — M. 

Fiant  pilulaj  No.  vi. 

Sig. — One  pill  two  or  three  times  daily. 

(Ganl.) 


534  FORMULARY 

Cholera  Drops  Useful  in  Acute  Diarrhea: 

I^     Olei  menthae  piperita; gr.  xlv  (3.0); 

Alcoholis 5  vj  (24.0) ; 

Tincturae  opii  et  saffroni 5ij  (8.0); 

Tinctura;  ipecacuanhae 5  vj  (24.0) ; 

Tincturas  Valeriana; 5iss  (45.0). — M. 

Sig. — One  to  two  fluid  rams  as  often  as  required. 

(Tiechman.) 

Diarrhea  or  Cholera  and  Cramps: 

I^     Chloralis  hydratis 3iij  (12.0); 

Morphina;  sulphatis gr.  j  (0.06); 

Atropinae  sulphatis gr.  3  (0.016); 

Aquae  chloroformi 3iv  (15.0); 

Aquae  distillatas oiv  (15.0). — M. 

Sig. — A  dose  is  20  miiiims,  repeated  every  ten  minutes  as  required. 

(Bartholow.) 

Cholera  Mixture: 

I^     Tincturae  capsici  ^ 

Tincturae  opii  ] 

Tincturae  rhei  )■ aa. — M. 

Spiritus  menthae  piperitae  | 
Spiritus  camphorae  J 

Sig. — Fifteen  to  30  drops  in  a  wineglass  of  water. 

(New  York  Sun.) 

Diarrhea  in  Cholera  Asiatica: 

I^     Tincturas  opii 6  parts; 

Vini  ipecacuanhae 4     " 

Tincturae  etheris  Valerianae 12     " 

Olei  menthae  piperitae i  part. — M. 

Sig. — Fifteen  to  25  drops  are  given  every  half-hour. 

{Miisser  and  Kelly.) 

Syphilitic  Diarrhea: 

I^     Hydrargyri  chloridi  corrosivi gr.  ij  (0.12); 

Potassii  iodidi 5v  (20.0); 

Ferri  et  ammonii  citratis 3  j  (4-o) ; 

TincturaS"  nucis  vomicae 3ij  (8.0) ; 

Tinctura;  gentianae  compositae q.  s.  ad  5iv  (120.0). — M. 

Sig. — Teaspoonful  three  times  daily. 

{Gant.) 

I^     Hydrargyri  iodidi  flavi gr.  xv  (i.o) ; 

Ferri  et  quininae  citratis 3iij  (i 2.0) ; 

Extracti  hyoscyami gr.  xij  (0.75). — M. 

Fiant  pilulae  No.  Ix. 

Sig. — One  pill  three  times  daily. 

{Gant.) 

I^     Hydrargyri  chloridi  corrosivi gr-  ij  (0.12); 

Potassii  iodidi 3  ij  (8.0) ; 

Syrupi sarsaparillae  compositae q.  s.  ad  %\y  (120.0). — M. 

Sig. — Teaspoonful  three  times  dailv. 

(Gant.) 

The  above  combinations  are  more  effective  when  their  daily  admin- 
istration is  reinforced  by  colonic  irrigations,  when  one  of  the  irrigating 
solutions  given  in  the  formulary  is  employed. 


CHRONIC    DIARRHEA    AND    COLITIS  535 

Diarrhea  and  Dysenteric  Colitis: 

JJ     Pulveris  catechu  compositae gr.  xv  (i.o); 

Syrupi  zinj^Mberis njjxl  (2.50) ; 

Tincture  o\n\ njiv  (0.24); 

Misturje  cretas q.  s.  ad  oj  (30-0). — M. 

Sig. — A  teaspoonful  to  be  taken  every  four  hours  while  diarrhea  continues. 

{Cant.) 

Chronic  Dysentery: 

I^     Tincturae  coto rrjjxx  (1.30); 

Tincturae  belladonnnc n^iij  (0.18); 

Tinctura;  nucis  vomicae njjiij  (0.18); 

Tinctura:  kramerias njxxx  (2.0); 

Decocti  tritici q.  s.  ad  5j  (30.0). — M. 

Sig. — Take  ever}'  four  hours. 

{Beasley.) 

Cathartic  in  Bacillary  Dysentery: 

I^     Olei  ricini 3iiss  (lo.o); 

Saloli gr.  xxvij  (1.75); 

Tincturas  opii  deodoratae gr.  x\'^  (i-o). — ^M. 

Pone  in  capsulas  No.  xw. 
Sig. — One  capsule  to  be  taken  every  two  hours. 

{Delafield.) 

Entamebic  (Dysentery)  Diarrhea: 

I^     Pulveris  ipecacuanhae gr.  ij  (0.12); 

Pulveris  opii gr.  3  (0.02) ; 

Hydrarg>-ri  chloridi  mitis gr.  I  (0.045). — ^^^ 

Pone  capsula  No.  i. 
Sig. — One  capsule  to  be  taken  everv  two  hours. 

(Sodre.) 

CHRONIC  DIARRHEA  AND  COLITIS 

The  following   formula;  are  to  be  relied  upon  in  the  treatment  of 
practically  all  forms  of  subacute  and  chronic  diarrheas,  viz.: 

Subacute  and  Chronic  Diarrhea  of  Phthisis: 

Bf     Argenti  nitratis gr-  iij  (o-i8); 

SjTupi  ipecacuanha; O  J  (30.0) ; 

Morphinse  sulphatis gr.  j  (0.065) ; 

Mucilaginis  acaciae q.  s.  ad  §ij  (60.0). — M. 

Sig. — A  teaspoonful  in  water  three  times  a  day  before  meals. 

(Shoemaker.) 

Chronic  Diarrhea.  Gastric  Catarrh,  or  Gastro-intrstinal  Catarrh  of  Phthisis: 

^     Codeina; gr.  iij  (0.18); 

-Argenti  nitratis gr.  vj  (0.36) ; 

Pulveris  acaciae q.  s.  ad. — M. 

Fiant  pilulae  No.  xx. 
Sig. — Give  one  pill  every  two  to  four  hours. 

(Shoemaker.) 

Chronic  Dysentery  and  Diarrhea: 

I^     Olei  ricini Oss  (2.0); 

Tinctura;  opii irjjxx  to  xxx  (1.30-2.0); 

Syrupi  sarsaparillae  or  .\qu3e  menthae  piperitae.  ...  Siss  (45-0); 

Pulveris  acacia; q.  s.  ad. — M. 

Sig. — One  or  two  teaspoonfuls  three  or  four  times  a  day. 

(Brunton.) 


oo^ 


FORMULARY 


Persistent  Diarrhea: 

I^     Pulveris  cretiE  compositae 5iii5s  (14.0); 

Bismuthi  subgallatis gr.  xl  (2.60); 

Aquae  menthae  piperitae q.  s.  ad  gi^'  (120.0). — M. 

Sig. — Tablespoonful  everv  three  or  four  hours. 

(Gant.) 

Diarrhea  of  Relaxation.  Especially  in  Elderly  Persons  (Hope's  camphor  mixture): 

'Sf    Acidi  nitrici npxxA-ij  (i  .So) ; 

Tincturae  opii njjxix  (1.24); 

Aquae  camphorae Siiiss  (loo.o). — M. 

Sig. — A  tablespoonful  ever>'  hour  or  two  according  to  sjTnptoms. 

{Hope.) 

Chronic  Diarrhea  u-ith  a  Dry  Tongue  and  Fl<iiul€ncy: 

'Sf     Olei  terebinthinae 3ss  (2.0) ; 

Olei  amygdalae  expressum 5ss  (15.0); 

Tincturae  opii 3  j  (4-o) ; 

Mucilaginis  acaciae o'^'j  (24-°); 

Aquje  lauro-cerasi q.  s.  ad  5 j  (30.0). — M. 

Sig. — One  teaspoonful  in  water  three  or  four  times  dailv. 

{Gant.) 

Chronic  Diarrhea  from  Hyperchlorhydria: 

I^     Acid  hydrochlorici  (Codex) gr.  vj  to  \-iij  (0.36-0.50) ; 

S>"Tupi  limonis oiiss  (lo.o); 

Aquae  distillatae q.  s.  ad  Oij  (looo.o). — M. 

Sig. — A  tumblerful  to  be  drunk  during  meak. 

The  ameUoration  of  SNTnptoms  will  be  manifest  in  three  or  four  davs. 

{Martin.) 

Sf     Tincturae  catechu §  j  (^Soo) ; 

Bismuthi  subsaUcAlatis ovj  (24.0); 

Pulveris  cretie  aromatic! oj  (^300); 

Aquae  chloroformi q.  s.  ad  Oj  (^500.0). — M. 

Sig. — Half  a  wineglass  two  or  three  times  a  day.  {Gant.) 

Sf    Tinctirrae  capsici itj»v  ('0.30) ; 

Acid  sulphurici  aromatici njjx  (0.6) ; 

Tincturae  opii njjv  (0.3) ; 

S\T-upi  aurantii oss  (2.0); 

Aquae  camphorae q.  s.  ad  5j  (30.0). — 'Si. 

Sig. — To  be  taken  three  times  a  day.  {Beasley.) 

^     Cretje  praeparata oij  (?>-o) ; 

Tincturae  catechu 5  ss  (^15.0) ; 

Tincturae  opii nplxxx  (5.0) ; 

Aquae  cinnamomi 3\'iij  (240.0). — M. 

Sig. — Two  tablespoonfuls  after  each  stool.  {Pother gill.) 

'Sf    SaloU. oij  (8.0); 

Bismuthi  subnitratis oi^'  (150); 

ilistune  cretae q.  s.  ad  oiij  (qo-o). — ^M. 

Sig. — One  tablespoonful  ever>-  two  hours.  {Gant.) 

'Sf    Resorcini gr.  iss  to  iij  (0.09-0.18) ; 

Tincturae  opii gtt.  ij  (o.i 2) ; 

Tincture  cascarillae gtt.  x^■  fi.o); 

Infusi  chamomil 5ij  (60.0). — M. 

Sig. — Teaspoonful  ever}-  two  hours.  {Kinderarzt.) 


HELMINTHIC     VXD    PROTOZOAL    COLITIS    (PARASITIC    DYSEXTERY)       537 

Chronic  Diarrhea  from  Ilyperchlorhydria: 

3     Potassii  bromidi 5iij  (12.0); 

Tincturac  opii 5ij  (8.0); 

Tincturac  capsici 5j  (4-o); 

Syrupi  rhei  aromatici q.  s.  ad  §iv  (120.0). — M. 

Sig. — One  teaspoonful  as  needed. 

(Bartholow.) 

I^     Argenti  nitratis gr.  v  (0.30) ; 

Extract!  hyoscyami gr.  x  to  xxx  (0.60-2.0); 

Extract!  opii gr.  ij  to  v  (o.  1 2-0.30) ; 

Pulveris  glycyrrhizas q.  s. — M. 

Fiant  piluhe  No.  xx. 
Sig. — One  pill  one  hour  before  each  meal.  (Ganl.) 

I^     Extracti  ergotae gr.  xx  (1.30); 

Extracti  nucis  vomicae gr.  v  (0.30); 

Extracti  opii gr.  x  (0.60). — ^M. 

Fiant  pilule  Xo.  xx. 
Sig. — One  pill  every  four  to  six  hours.  (DaCosta.) 

1^     Morphinae  sulphatis gr.  jJ-o-  (0.005); 

Bismuthi  subnitratis gr.  v  (0.30). — M. 

Fiant  chartulae  Xo.  i. 
Sig.-^One  powder  three  or  four  times  daily.     (In  chronic  cases.) 

(Alouzo  Clark.) 

J\     Tinctura;  opii  camphorae ")  --   *      r        \ 

Bismuthi  subnitratis         \ ^^  ^^^  K^S-o); 

Misturse  cretje q.  s.  ad  §iv  (120.0). — M. 

Sig. — Two  teaspoonfuls  in  water  ever>'  two  or  three  hours.     Shake. 

(Kemp.) 

I^     Argenti  nitratis gr.  v  (0.30); 

Resinje  terebinthinae  1  ._-.., 

Liquoris  potassae         j ^^   ^•'    '^■°'^ ' 

Pulveris  glycyrrhizae q.  s. — ]\L 

Fiant  pilulae  Xo.  xx. 
Sig. — One  pill  three  times  daily.  (Kemp.) 

R     Pulveris  opii       }  __  /        ^ 

^      .         ,•     .'     ,•       aa  gr.  V  (0.30); 

Argenti  nitratis  1  o         v    o  /> 

Resinas  terebinthinae 5ij  (8.0); 

Liquoris  potassa; 5j  (4-o); 

Pulveris   glycyrrhizae q.  s. — M. 

Fiant  piluhe  Xo.  Ix. 

Sig. — Two  or  three  pills  three  times  a  day. 

(Thompson.) 

HELMINTHIC  AND  PROTOZOAL  COLITIS    (PARASITIC  DYSENTERY) 

Hcl  mini  hie  Catarrh,  Diarrhea,  or  Constipation — Cestodes,  Flat  (Tenia),  Solium   (pork), 
Saginata  (beef),  Lata  (fish),  and  X'ana  (dwarf): 
(i)  Place  patient  on  a  fluid  diet  for  twenty-four  hours. 

(2)  Clear  the  bowel  thoroughly  with  a  hydragogue  cathartic.     (Salts  or  calomel.) 

(3)  Administer  a  teniafuge  (anthelminthic)  such  as  felix  mass  (male  fern),   5ss  to  ij 

(2.0-8.0);  fluidextract  of  granatum  (pomegranate  root),  oss  to  ij  (2.0-8.0); 
pumpkin-seed  or  pelletierin.  gr.  v  to  vij  (0.30-0.45).  to  dislodge  the  parasite. 

(4)  Give  castor  oil,  5  j  (30.0).  or  a  liberal  dose  of  calomel,  gr.  v  (0.30).  followed  by  salts 

(magnesium  citrate  or  sulj^hate,  o  j  to  ij — 4.0-8.0),  shortly  following  the  tenia- 
fuge to  cause  ex-pulsion  of  the  worm. 

(5)  When  the  helminth  has  been  expelled  a  search  should  be  made  for  its  head,  which, 

if  found,  indicates  that  the  treatment  has  been  completely  successful.     In 
aggravated  cases  the  above  vermifuges  may  be  combined  to  advantage. 


538 


FORMULARY 


When  male  fern  fails  to  bring  the  worm,  the  following  combination 

will  be  found  useful: 

I^     Extract!  tilicis  macis  aether gtt.  Iviij  (4.0); 

Chloroformi gtt.  vj  (0.36) ; 

^Je^V^^i.  .     I aa  5j(3o.o); 

Mucilaginis  acaciae  J  "j  w 

Aquse  distillatas q.  s.  ad  5viss  (200.0). — M. 

Fiant  emulsio. 
Sig. — Introduce  through  a  stomach-tube  in  the  morning. 

{Cohnheim.) 
Nematodes  {Round-  and  TJircad-worms): 

Hookworms:  These  helminths  can  always  be  eradicated  by  the  administration  of  four 
doses,  one  hour  apart,  of  beta-naphthol  or,  preferably,  thymol  in  15-gr.  (i.o)  doses 
following  a  two-days'  fluid  diet  and  cleaning  of  the  bowel  with  a  saline.  A  second 
dose  of  salts  should  be  administered  after  the  last  of  thymol  to  wash  out  the  inert 
or  dead  worms. 

(Gant.) 

Lunibricoid  Worms:  Patients  afflicted  with  Ascaris  lumbricoides  should  be  advised  to 
destroy  their  stools  and  scour  their  hands  after  defecation  to  prevent  e.xtension  of  the 
infection  to  others. 

Santonin,  gr.  ij  to  v  (0.12-0.30),  alone  or  in  conjunction  with  castor  oil,  is  usually 
effective  against  these  parasites  when  administered  for  three  successive  evenings  and 
followed  by  a  purge,  particularly  when  the  bowel  has  been  emptied  prior  to  the  iirst 
dose. 

Hydrargyri  chloridi  mitis  / ^  '        ^  '     '' 

Sacchari q.  s. — M. 

Fiant  chartula;  No.  vi. 
Sig. — A  powder  night  and  morning.  {Cohnheim.) 

For  a  detailed  discussion  of  helminthic  and  protozoal  colitis  (para- 
sitic dysentery)  the  reader  is  referred  to  Chapters  XXXVII  and 
XXXVIII. 

ENEMATA  AND  IRRIGATING  SOLUTIONS  IN  THE  TREATMENT  OF  DIARRHEA 
DUE  TO  CATARRHAL  OR  ULCERATIVE  (SPECIFIC)  COLITIS 

I^     Sodii  biboratis 5ij  (8.0); 

Extracti  krameriae  fluidi q.  s.  ad  5iv  (120.0). — M. 

Sig. — Put  a  tablespoonful  in  a  quart  (1000  c.c.)  of  warm  water  and  irrigate  the  colon 
daily  until  stools  are  fewer  in  number,  and  mucus,  pus,  and  blood  disappear. 

{Gant.) 

This  formula  acts  exceedingly  well  when  the  mucosa  is  inflamed  or 
dotted  over  with  erosions  or  superficial  ulcers. 

I^     Acidi  tannici 3j  (4-o); 

Amyli 5ss  (15.0); 

Aquae q.  s.  ad  Oij  (looo.o). — M. 

Sig. — Inject. 

{Cohnheim.) 

'Sf,     Pulveris  opii gr.  ij  to  v  (0.12-0.30); 

lodoformi Sss  to  j  (2.0-4.0); 

Bismuthi  subnitratis 5ij  (60.0) ; 

Olei  olivae q.  s.  ad  Oij  (looo.o). — M. 

Fiant  emulsio. 
Sig. — Warm  and  inject,  or  pour  4  ounces  or  more  into  the  colon  through  sigmoidoscope 
while  the  patient  is  in  the  inverted  posture.     Repeat  the  treatment  three  times  weekly. 

{Gant.) 


INFANTS    AND    YOUNG    CHILDREN  539 

This  emulsion  (luickly  relie\-es  intestinal  burning  and  tenesmus,  and 
stimulates  healing  when  the  Ixnvel  is  highly  inflamed  and  sensitive 
or  ulcerated. 

Dysenteric  Diarrhea  (Sublimate  Enema) : 

I^     Hydrargyri  corrosivi gr.  ij  to  iij  (o.i  2-0.18); 

Aquae Oj  (500.0) ; 

Alcoholis q.  s. — M. 

Sig. — For  two  injections,  one  in  the  morning  and  one  in  the  evening. 

(Bonamy.) 

Enefna  for  Feeble  Patients  having  Dysenteric  Chronic  Diarrhea: 

I^     Sodii  biboratis 3j  (4-o); 

Tinctura;  benzoini 3j  (4-o); 

Spiritus  camphorae 5j  (30.0); 

Aqu£e  distUlatas q.  s.  ad  Oij  (looo.o). — M. 

Sig. — Inject. 

(Cant.) 

Mucomembranous  Enteritis  -with  Diarrliea: 

R     Bismuthi  subnitratis  I  __►-..     ,        v 

Bismuthi  saHcylatis  r\ aa  o  nss  (lo.o) ; 

^lucilaginis  cydonii  (quince  seed) Oj  (500.0). — M. 

Sig. — For  rectal  injection. 

{Revilliod.) 

Chronic  Colitis: 

I^     Resorcini gr.  v  to  x  (0.30-0.65) ; 

Aquae  distillatae Oij  (looo.o). — M. 

Sig. — Use  for  enteroclysis. 

{Cant.) 

INFANTS  AND  YOUNG  CHILDREN 

Diarrhea  of  Secondary  Sepsis: 

I^     Bismuthi  subcarbonatis gr.  .x  (0.60); 

Glycerini njx  (0.60) ; 

Sodii  salicylatis gr.  j  (0.06) ; 

Aquae  distillatae q.  s.  ad  oj  (4-o)-^ — M. 

Sig. — Teaspoonful  everj-  three  or  four  hours. 

{Cant.) 

Dysenteroid  Diarrhea  -u-ith  Mucus  and  Blood  in  the  Stools  and  Tenesmus: 

I^     Olei  ricini njij  (0.12); 

Tincturaj  opii         )  aa  npss  (o  o^t)- 

\  ini  ipecacuanhas  j " 

Glycerini njjx  (0.60) ; 

Aqua;  cinnamomi q.  s.  ad   oj  (4-o). — M. 

Sig. — Teaspoonful  every  four  hours. 

(Cant.) 

Diarrhea  ivith  Foul-smelling  Stools: 

'Sf     Resorcini gr.  ss  (0.03); 

Tincturae  rhei  aromaticae njiij  (0.18); 

Tincturae  opii nj^  (0.02) ; 

Tincturae  cardamomi  compositae irjjv  (0.30); 

Aquae  chloroformi ttjv  (0.30) ; 

Aquae  mentha;  piperita; q.  s.  ad  5j  (4-°). — M. 

Sig. — Teaspoonful  three  times  daily. 


540  FORMULARY 

DiarrJiea  with  Fluid  Movements: 

1$     Spiritus  ammoniae  aromatici tijss  (0.03) ; 

Tincturae  rhei  aromaticae TiEiij  (0.18); 

Glycerini ngx  (0.60J ; 

Aquae  distillatas q.  s.  ad  oj  (4-o). — M. 

Sig. — Teaspoonful  even"  four  hours. 


Infantile  Diarrhea  n'ith  Greenish  Stools  Accompanied  by  Abdominal  Pain: 

I^     Bismuthi  subnitratis gr.  xlv  (3.0) ; 

Liquoris  calcis f oiss  (6.0); 

Aqu£e  foeniculi q.  s.  ad  oij  (60.0). — M. 

Sig. — Teaspoonful  even-  two  hours. 

{Modified  after  Grimes.) 


DIARRHEA  OF  OLDER  CHILDREN 

The  dosage  given  below  must  be  studied  and  changed  according 
to  the  patient's  age: 

I^     Bismuthi  subcarbonatis OSS  to  iss  (2.0-6.0); 

Spiritus  myristicae npxx  (1.30); 

Spiritus  \\m  gallici f  5ij  (8.0); 

Aquae  cinnamomi q.  s.  ad  fsiij  (90.0). — M. 

Shake  well. 
Sig. — Teasjx)onful  even-  two  hours. 

{Bennett.) 

I^     Spiritus  camphorae  ^ 

Tincturae  capsici  i  ..    -.  ,        ■, ,, 

Spiritus  menth£  piperitae   \ ^^   ^^  '^°-°^-     -^^• 

Tincturae  rhei  aromatic^    j 
Sig. — One  to  5  drops  in  water  everj-  two  hours 

{Rnschenberger.) 

I^     Spiritus  camphors foss  (2.0); 

Spiritus  \Tni  galUci q.  s.  ad  foij  (60.0). — M. 

Sig. — Twenty  drops  ever>-  two  or  three  hours  in  cases  of  prostration  from  diarrhea. 

{Gant.) 

3     Camphor gr.  ss  (0.3); 

Sterile  olive  oil njx  (0.60). — ^M. 

Sig. — H>-podermically.  in  cases  of  collapse  as  a  quick  diffusible  stimulant. 


Acute  Diarrhea  and  Dysentery  Complicated  by  Severe  Pain  and  Tenesmus: 

H     Cocainae  hydrochloratis _, gr.  j  (0.65) ; 

Extractae  ergotae gr.  j  (0.65) ; 

Extractum  opii gr.  iss  (0.09) ; 

Thymolis  iodidi gr.  iv  (0.24); 

Olei  theobromatis gr.  cl  (6.0). — M. 

Fiant  suppositoria  Xo.  x. 
Sig. — One  suppository-  to  be  used  ever>-  three  hours  after  preliminarj-  treatment. 

(Gant.) 

1$     Xaphthalini gr.  xij  to  oj  (o-75-4o); 

Sacchari  lactis gr.  xij  to  oss  (0.75-2.0). — M. 

Fiant  chartulae  Xo.  xii. 
Sig. — One  powder  ever>'  three  hours. 

(Starr.) 


DIARRHEA    OF    OLDliR    CHILDREN  54I 

Acute  Diarrhea  and  Dysentery  Complicated  by  Severe  Pain  and  Tenesmus: 

I^     Magnesii  sulphatis 5 j  (4-o) ; 

Aqua;  tinnamomi q.  s.  ad  f5j  (30.0). — M. 

Sig. — Teaspoonful  ever}-  two  hours  for  a  child  of  one  or  two  years  where  saline  cathar- 
sis is  indicated. 

I^     Extracti  hiematoxyli gr.  iss  (0.09) ; 

Tincture  krameriae njiiiss  (0.20); 

Glycerini TTijxij  (0.75); 

AcjUK q.  s.  ad   5j  (4-o). — M. 

Sig. — Teaspoonful  three  times  daily. 

(Gant.) 

I^     Phenj'lis  salicylatis .  .  .   gr.  iss  (o.oq)  ; 

Bismuthi  subnitratis gr.  iv  (0.24); 

Pulveris  cretas  aromaticae  cum  oi)ii gr-  ss  (0.03). — M. 

Fiant  chartula;  No.  i. 
Sig. — To  be  given  with  10  drops  of  glycerin  three  times  daily. 

(Can  I.) 

Chronic  Intestinal  Diarrhea  with  Offensive  Stools;  Chronic  Dysentery  and  Colitis: 

I^     Bismuthi  subnitratis gr.  v  (0.30J ; 

Benzonaphtholi gr.  j  (0.06); 

Pulveris  ipecacuanhae  et  opii gr.  75  (o-oos) ; 

Sacchari  albi gr.  iss  (o.io). — M. 

Fiant  chartulae  No.  i. 
Sig. — Of  these  j^owders  children  may  be  given  five  daily,  one  about  every  three  hours. 
The  average  dose  for  children  up  to  one  year  is  0.05  altogether;  0.25  gm.  daily;  for  children 
of  two  years  o.i  gm.  per  dose  and  0.5  gm.  daily. 

{Zentralblatl  f.  d.  gesammte  Therapie.  28,  1910.) 
Note. — Useful  after  all  food  elements  have  been  removed. 

Acute  Colitis  and  Ileocolitis  (Dysentery): 
I^     Bismuthi  subnitratis  ^ 

Tincturai  catechu  compositae  I  ..„..,„    \. 

Tincturae  krameriae  f o  }  {  ■  J, 

Tincturae  oj^ii  camphoratae     J 

Misturas  cretae q.  s.  ad  oiv  (120.0). — M. 

Sig.- — Teaspoonful  everj'  two  hours. 

(Maiircr.) 

In  all  varieties  of  acute  and  chronic  inflammation,  and  ulcerative 
lesions  accompanied  by  diarrhea  or  mucoid  and  bloody  stools,  silver 
nitrate,  potassium  permanganate,  ichthyol,  zinc  sulphate,  fluidex- 
tract  of  hydrastis,  sodium  salicylate,  i  to  2  per  cent.,  are  always  elTect- 
ive  when  they  are  made  to  reach  all  parts  of  the  invaded  bowel.  The 
strength  of  irrigating  solutions  may  be  doubled  in  obstinate  cases. 

When  ulceration  is  extensive  and  diarrhea  is  very  persistent,  in 
case  the  stools  are  exceedingly  offensive,  they  can  be  successfully  dis- 
infected by  flushing  the  intestine  twice  daily  with  a  5  per  cent,  ichthyol 
solution  of  kerosene  (lamp  oil)  or  20  per  cent,  hydrogen  peroxid 
solution. 


CHAPTER   XLIX 

SURGICAL  TREATMENT  OF  DIARRHEAL,  INFLAMMATORY, 
OBSTRUCTIVE,  AND  PARASITIC  DISEASES  OF  THE 
GASTRO-INTESTINAL   TRACT 

GENERAL  REMARKS,   PREPARATION  OF  PATENT 

H.wnxG  elsewhere  discussed  other  measures  useful  in  the  treat- 
ment of  this  class  of  afiections,  the  author  will  now  outline  their  sur- 
gical treatment.  Some  of  the  procedures  are  simple,  but  other  opera- 
tions are  abdominal,  and  require  a  skilled  surgeon. 

Surgical  intervention  should  not  be  practised  in  the  treatment  of 
diarrheal,  catarrhal,  and  parasitic  diseases  until  after  other  and  less 
radical  therapeutic  measures  have  failed  to  benefit  the  patient,  except 
when  it  is  evident  that  the  trouble  is  incident  to  acute  or  chronic  in- 
testinal obstruction,  in  which  case  an  operation  is  indicated  at  the  first 
opportunity.  Operative  interference  is  also  imperative  in  the  presence 
of  intestinal  cancer,  and  in  neglected  cases  where  the  patient  is  suffering 
profoundly  from  diarrhea,  toxemia,  exhaustive  discharges,  and  exten- 
sive ulcerative  lesions  of  the  bowel  complicated  by  mixed  infection. 
On  the  other  hand,  operative  procedures  should  not  be  withheld 
and  the  sufferer  daily  drugged  to  control  diarrhea  when  it  has  been 
demonstrated  that  the  treatment  is  not  curative,  because  medicines 
employed  for  the  purpose  disturb  the  stomach,  interfere  with  the 
secretions  and  peristalsis,  and  the  patient  often  becomes  addicted  to 
them,  and,  further,  because  many  of  these  sufferers  can  be  quickly  and 
permanently  cured  by  operations  that  are  almost  devoid  of  danger, 
take  but  a  short  time,  and  keep  the  patient  in  bed  but  a  few  days. 
Many  physicians  assert  that  their  patients  will  not  submit  to  opera- 
tion, but  the  author  holds  that  the  opposite  is  true,  and  that  sufferers 
from  either  chronic  constipation  or  diarrhea  insist  upon  operative 
interference  as  soon  as  they  are  convinced  that  a  correct  diagnosis 
has  been  made,  and  that  radical  treatment  will  permanently  help  them, 
for  they  are  willing  to  do  anything  which  will  relieve  them  from  con- 
stant dieting  and  drugging.  The  author  has  had  a  ver\-  extensive  ex- 
perience with  the  surgical  treatment  of  diarrheal,  catarrhal,  and  para- 
sitic diseases  of  the  stomach  and  intestines,  and  the  results  have  been 
almost  universally  good,  and  in  consequence  he  has  no  more  hesitation 
in  recommending  an  operation  in  this  class  of  cases  than  for  other 
surgical  diseases. 

Operative  measures  are  seldom  required  in  the  handling  of  acute 
inflammatory-  and  ulcerative  lesions  of  the  intestine  responsible  for 
catarrh  or  diarrhea,  since  they  can  be  Felieved  by  the  simple  measures 
outlined  elsewhere. 
542 


PKHPA RATION    OF    THE    PATIENT  543 

Where  loose  movements  are  incident  to  chronic  intestinal  obstruc- 
tion a  prompt  cure  usually  follows  correction  or  removal  of  the  lesion, 
but  when  catarrh  or  diarrhea  is  caused  by  simple  or  specific  inflam- 
matory or  ulcerati\-e  lesions  a  course  of  postoperative  treatment  of 
days,  weeks,  or,  possibly,  months  may  be  necessary  to  heal  them 
subsequent  to  intestinal  exclusion,  appendicostomy,  cecostomy,  colos- 
tomy, or  resection. 

Multiple  operations  are  indicated  now  and  then  to  relieve  individuals 
suffering  from  chronic  diarrhea,  for  in  one  of  the  author's  recent  cases 
the  colon  was  obstructed  by  an  angulation,  extensively  ulcerated,  and 
the  rectum  was  blocked  by  a  large  polyp,  all  of  which  were  corrected 
by  separate  procedures.  It  is  frequently  necessary  to  do  an  appendi- 
costomy or  cecostomy  in  connection  with  resection  and  other  opera- 
tions performed  for  the  relief  of  chronic  bowel  blocking  to  quickly 
overcome  the  toxemia,  heal  ulcers  or  an  inflamed  mucosa,  and  hasten 
the  patient's  convalescence. 

Occasionally  one  is  justified  in  delaying  surgical  intervention  and 
giving  a  prolonged  trial  to  less  radical  measures  where  patients  ha\'e 
plenty  of  strength,  time,  and  money,  but  individuals  who  work  for  a 
living  should  be  operated  upon  as  soon  as  it  has  been  demonstrated 
that  diet,  medicine,  and  irrigation  (from  below),  etc.,  fail  to  perma- 
nently improve  them. 

Many  types  of  diarrhea  herein  discussed  are  curable  with  ordinary 
measures;  but  loose  movements  incident  to  chronic  intestinal  obstruc- 
tion, a  highly  inflamed  or  ulcerated  mucosa,  constipation  with  recurring 
fecal  impaction,  irritation  or  occlusion  from  parasites,  often  cannot 
be  permanently  arrested  except  by  operative  procedures. 

Before  describing  individual  procedures  the  author  will  briefly 
discuss  the  method  of  preparing  the  patient  and  other  points  concerned 
in  the  general  technic  of  abdominal  and  other  operations  to  be  dis- 
cussed . 

Preparation  of  the  Patient. — The  method  of  preparing  the  patient 
depends  upon  whether  or  not  the  abdomen  is  to  be  opened  or  the 
rectum  operated  upon.  Except  in  emergency  cases  subjects  requiring 
laparotomy  should  remain  in  the  hospital  two  or  more  days  prior  to 
the  operation  that  they  may  become  accustomed  to  their  surroundings 
and  give  the  attendant  an  opportunity  to  cleanse  the  bowel.  There 
are  many  laxatives  and  cathartics  for  the  purpose,  but  the  author 
prefers  licorice  powder,  oj  to  ij  (4.0-8.0),  a  saline,  gss  (15.0),  or  when 
the  patient  is  bilious,  calomel  and  soda,  gr.  |  (0.03),  administered 
every  twenty  minutes  until  five  doses  have  been  taken,  when  it  is 
followed  the  next  morning  by  salts  or  a  mineral  water. 

When  the  intestine  is  blocked  b\-  an  obstruction  or  there  is  fecal 
impaction,  i  or  2  ounces  of  castor  oil  usually  proves  effective.  Ene- 
mata  of  soapsuds,  water,  or  oil,  alone  or  admixed,  are  useful  for  cleans- 
ing the  colon,  sigmoid  flexure,  and  rectum. 

Where  intestinal  resection  or  rectal  extirpation  is  contemplated 
more  time  is  required,  and  several  days  should  be  spent  in  freeing  the 


544      SURGICAL    TREATMENT    OF    THE    GASTRO-INTESTINAL    TRACT 

intestine  of  retained  feces  and  opiates,  or  astringents  should  be  ad- 
ministered several  hours  before  the  operation  to  arrest  peristalsis  and 
the  secretions,  so  that  the  lower  bowel  will  be  empty  at  the  time  of 
operation. 

Formerh-,  the  author  had  the  abdomen  shaved,  thoroughly  cleansed, 
and  covered  with  antiseptic  dressings,  but  recently  the  latter  have 
been  omitted  and  chief  reliance  placed  on  an  iodin  solution,  which  is 
painted  over  the  clean  dry  skin  and  then  washed  ofif  with  alcohol 
just  before  the  operation  is  begun.  In  abdominal  cases  the  patient 
should  urinate  or  be  catheterized  before  he  enters  the  operating  room, 
otherwise  the  bladder  may  be  opened,  as  occurred  in  one  of  the  author's 
cases. 

When  the  rectum  is  to  be  remo\ed  or  extensively  operated  upon 
the  patient  should  be  prepared  according  to  the  above  plan ;  but  when 
an  abscess  is  to  be  incised,  hemorrhoids  removed,  the  sphincter  divulsed 
or  cut,  and  in  other  minor  procedures,  elaborate  preparations  are  un- 
necessary and  should  be  discarded  for  an  enema,  consisting  of  not 
more  than  6  ounces  of  water,  which  will  empty  and  cleanse  the  rectum. 
When  the  author  has  been  bothered  with  feces  running  over  the  opera- 
ti\e  field  it  has  usually  occurred  in  cases  where  the  all-wise  intern 
has  administered  a  strong  cathartic  the  previous  night  and  a  copious 
colonic  enema  shortly  prior  to  the  operation. 

Of  the  operations  called  for  in  the  surgical  treatment  of  diarrheal, 
inflammatory,  and  parasitic  diseases  of  the  gastro-intestinal  tract,  the 
following  are  the  most  useful — viz.: 

(i)  Cecostomy  (Gibson's  and  Gant's). 

(2)  Appendicostomy. 

(3)  Appendicocecostomy. 

(4)  Appendico-enterocecostomy. 

(5)  Enterostomy. 

(6)  Colostomy. 

(7)  Resection  and  extirpation  (enterectomy,  cecectomy,  colectomy, 
sigmoidectomy,  and  proctectomy). 

(8)  Sigmoidectomy  and  proctectomy. 

(9)  Intestinal  exclusion. 


CHAPTER   L 


SURGICAL  TREATMENT  OF  DIARRHEAL,  INFLAMMATORY, 
OBSTRUCTIVE,  AND  PARASITIC  DISEASES  OF  THE 
GASTRO-INTESTINAL   TRACT    [Continued) 

APPENDICOSTOMY,    APPENDICOCECOSTOMY,    CECOSTOMY 

HISTORIC  NOTE,   GENERAL  REMARKS 

Historic  Note. — Twenty  years  ago  the  direct  or  through-and- 
through  irrigating  treatment,  now  frequently  employed  for  the  relief 
of  diarrhea,  catarrhal  and  infectious  colitis,  and  many  other  diseases 
of  the  colon,  was  unknown.  Mayo  Robson  (1893)  arid  Hale  White 
(1895)  reported  cases  of  membranous  colitis  cured  by  right-sided  colos- 
tomy and  bowel  flushing.  Gibson  (1902)  described  his  valvular  cecos- 
tonjy,  and  Weir,  in  the  same  year,  published  his  method  of  irrigating  the 
colon  through  the  appendix,  a  procedure  Willy  Meyer  named  appendi- 
costomy.  In  1908  the  author  described  his  cecostomy  which  provides  a 
means  of  separately  or  simultaneously  irrigating  the  colon  and  small  intes- 
tine} In  1910-  he  published  a  modification  of  this  procedure,  described 
his  enterocolonic  irrigator  used  in  connection  with  it,  and  at  the  same 
time  gave  the  steps  and  illustrated  the  technic  of  his  appendicostomy, 
reporting  105  cases  (see  accompanying  table)  of  bowel  affections  treated 
by  through-and-through  irrigation,  since  which  time  he  has  had  an 
additional  100  cases. 

TABLE  SHOWING  OPERATIONS  AND  AFFECTIONS  FOR  WHICH  DIRECT 
BOWEL  TREATMENT  WAS  EMPLOYED  BY  THE  AUTHOR  IN  105 
ADULTS.     (These  operations  were  performed  prior  to  19 10.) 


c 

Operations  performed  for: 

0 

.S  2 

si 

'0 

D. 

.E  " 
'3.E 
£  = 

c 

D 

p.  ^ 

■5  " 

si 

J3  ■" 

c 
.0 
"c 

ultiple  polyp 
of  colon  and 
rectum. 

olonic  ulcera- 
tion compli- 
cating invagi 
nation  and 
constipation 
operated  upo 
by  colopexy 
and  siKmoid- 
opcxy. 

^ 

u 

" 

cu 

u 

a 

^ 

U 

g 

U 

V 

Appendicostomy 

48 

4 

I 

2 

I 

2 

I 

0 

4 

63 

Appendicocecostomy 

4     0 

0 

0 

0 

0 

0 

0 

2 

6 

Gibson's  operation 

6     2 

0 

2 

0 

I 

0 

2 

I 

14 

.Author's  cecostomy 

19     I 

2 

0 

4 

0 
I 

0 

0           0 

I 
8 

22 

Number 

77 

7 

3 

I             2 

lOS 

Since  Weir,  Gibson,  and   the  author  outlined  the  lechnic  of  the 
above  operations  they  ha\e  lieen  extensively  employed  in  the  treat- 


^  New  York  Med.  Jour.,  .\ugust  15. 
'^  Interstate  Med.  Jour.,  vol.  xvii,  No.  9. 


35 


545 


546      SURGIC\L    TREATMENT    OF    THE    GASTRO-INTESTINAL    TRACT 

ment  of  colitis  and  other  diseases  mentioned  below,  and  many  valuable 
papers  by  various  authorities  have  been  published  concerning  modifica- 
tions in  their  technic  and  suggesting  new  fields  of  usefulness  for  them. 
The  author  became  convinced  years  ago  that  ulcerative  colitis  and 
other  affections  responsible  for  chronic  diarrhea  required  local  treat- 
ment, and  that  medicine  and  dieting  were  of  secondary  importance  in 
such  cases.  In  his  teaching,  books,  and  articles  in  current  litera- 
ture he  has  done  his  best  to  emphasize  the  value  of  medicated  bowel 
irrigation  in  the  treatment  of  chronic,  inflammatory,  ulcerative,  and 
parasitic  diseases  of  the  colon,  and  to  point  out  the  value  of  appendi- 
costomy,  cecostomy,  colostomy,  etc.,  and  through-and-through  colonic 
flushing  in  cases  where  the  solution  cannot  be  made  to  reach  all  parts 
of  the  large  bowel  when  introduced  from  below.  A  summary  of  the 
author's  most  important  contributions  along  this  line  are  given  below: 

(i)  Report  of  3  cases  of  membranous  coloproctitis  cured  by  colostomy  and  irrigation 
(Gant,  Diseases  of  the  Rectum  and  Anus,  2d  ed.,  p.  222,  1902). 

(2)  Tubercular  colitis  cured  by  colostomy  and  irrigation  with  closure  of  the  artificial 
anus  at  end  of  the  third  year  (Review  of  Reviews,  October,  1900). 

(3)  Report  of  9  cases  of  dysentery  and  diarrhea  treated  by  appendicostomy  or  cecos- 
tomy and  irrigation  (Boston  !NIed.  and  Surg.  Jour.,  September  6,  1906). 

(4)  Report  of  35  appendicostomies  and  12  cecostomies  (New  York  Med.  Jour.,  Au- 
gust 15,  1908). 

(5)  Surgical  Treatment  of  Diarrhea,  with  Description  of  a  New  Cecostomy  which 
Permits  Free  Irrigation  of  the  Small  and  Large  Intestines  (New  York  ]\Ied.  Record,  Sep- 
tember II,  1909). 

(6)  Some  Original  Surgical  Procedures  (which  included  a  description  of  a  new  modi- 
fication of  Gant's  cecostomy,  enterocolonic  irrigator,  and  appendicostomy),  an  address 
delivered  before  the  Cleveland,  Ohio,  Academy  of  IMedicine,  November  19,  1909. 

(7)  Cecostomy  and  Appendicostomy  in  the  Treatment  of  Intestinal  Affections,  with 
a  Report  of  105  Cases  of  Bowel  Diseases  Treated  by  the  Direct  IMethod  (Interstate  Aled. 
Jour.,  vol.  xvii.  No.  9,  1910). 

(8)  Constipation  and  Obstipation  (Gant,  19 10). 

(9)  Analytical  and  Statistical  Study  of  Bowel  Diseases  in  Infancy  and  Childhood,  etc. 
(American  Medicine,  June,  191 1). 

(10)  Intestinal  Tuberculosis  (The  Post-Graduate,  June  13,  1913). 

(11)  Surgical  Myxorrhea  Coli — M.  Mem.branacea  and  M.  Colica  (Surg.,  G>ti.,  and 
Obstet.,  December,  19 14). 

(12)  Modernized  Proctology  (N.  Y.  Med.  Jour.,  January  16,  1915). 

General  Remarks. — Appendicostomy  and  cecostomy  are  called 
for  more  often  than  other  operations  in  the  treatment  of  chronic  diar- 
rhea, and  are  generally  practical  where  the  mucosa  is  extensively 
involved  by  a  catarrhal,  tubercular,  entamehic,  hacillary,  balantidic, 
helminthic,  luetic,  membranous,  gonorrheal  or  mixed  infection  colitis, 
ptomain- poisoning,  chronic  intestinal  obstruction,  colonic  polypi,  papil- 
lomata,  and  other  bowel  affections  complicated  by  an  inflamed  or 
ulcerated  mucosa,  profuse  discharge  of  pus,  blood,  and  mucus,  or  intes- 
tinal hemorrhage. 

Some  idea  may  be  formed  of  the  wide  usefulness  of  appendicostomy 
and  cecostomy  by  studying  the  following  list  of  diseases  and  sym[)- 
toms,  in  the  treatment  of  which  they  have,  with  varying  frequenc>-. 
been  employed — viz.,  catarrhal  and  specific  inflammatory  and  ulcera- 
tive lesions  of  the  colon,  sigmoid  and  rectum,  intestinal  cancers,  stric- 


GENERAL    REMARKS  547 

Hires  and  tumors,  chronic  intestinal  obstruction  incident  to  angulations, 
twists,  ptosis,  extra-intestinal  pressure,  invagination,  etc.,  constipation 
with  recurring  coprostasis,  intestinal  auto-intoxication,  myxorrhea 
membranacea  and  colica,  ordinary  and  pernicious  anemia,  ptomain- 
poisoning,  helminths,  and  other  intestinal  parasites,  pain  and  colic 
from  bowel  disturbances,  pneumococcic  colitis,  typhoid  Jever,  paralytic 
ileus,  septic  and  tubercular  peritonitis,  diverticulitis,  simple  and  mem- 
branous pericolitis,  epilepsy  (complicated  by  intestinal  auto-intoxica- 
tion), leukocytosis,  malnutrition  (to  facilitate  artificial  feeding),  acute 
and  recurring  gas  distention,  defective  intestinal  flora,  ileocecal  and  colonic 
intussusception,  hemorrhagic  colitis,  tympanites  of  lobar  pneumonia, 
appendicitis  (where  the  appendix  is  infected),  gastric  ulcer,  cancer, 
and  stricture,  etc.  (where  artificial  feeding  and  rest  of  the  organ  were 
indicated),  shock  (to  increase  the  circulating  fluid  by  the  introduction 
of  a  saline  solution),  deficient  peristalsis  (to  augment  muscular  activity), 
raise  or  lower  the  temperature  (by  the  introduction  of  hot  and  cold 
solutions  into  the  bowel),  intestinal  fermentation  and  putrefaction  (that 
putref\ing  food  remnants,  bacteria,  and  toxins  may  be  washed  out), 
general  debility  (to  permit  colonic  oxygen  baths,  which  exhilarate  the 
patient,  improve  the  blood,  and  forestall  collapse  during  extensive 
operations). 

Appendicostomy  and  cecostomy  ha\e  also  been  employed  as 
substitutes  for  gastrostomy,  jejunostomy,  colostomy,  Lanes  colonic  re- 
section for  colonic  stasis  following  resection,  intestinal  exclusion  and 
fixation  of  the  bowel  to  the  abdominal  parietes  to  prevent  tension 
upon  the  sutures  incident  to  gas  distention,  to  provide  drainage  and 
forestall  the  backing  of  discharges  and  feces  when  the  bowel  has  been 
short-circuited,  and  as  a  preliminary  procedure  to  resection  for  intestinal 
cancer,  stricture,  and  ulceration;  and  \'er  Hoogan,  following  total  cys- 
tectomy (2  cases)  and  transplantation  of  both  ureters  into  the  cecum  after 
its  exclusion,  performed  appendicostomy  to  insure  drainage  of  the 
urine,  but  the  patients  died  within  a  few  h(jurs. 

Hollis,  Ditmar,  Burch.  and  the  author  have  successfully  treated 
cases  of  pernicious  anemia  with  appendicostomy  or  cecostomy  and 
through-and-through  irrigation,  and  it  is  likely  that  the  benefit  derived 
was  due  to  the  flushing  out  of  intestinal  toxins  elaborated  by  the 
anaerobic  bacteria  peculiar  to  the  colon,  for  Herter  has  demonstrated 
that  oxygen  is  confined  to  the  small  bowel. 

The  author  has  operated  upon  many  patients  suffering  from  in- 
testinal auto-intoxication,  ulceration,  or  chronic  obstruction  where 
anemia  was  a  serious  complication,  and  in  every  instance  the  condition 
was  markedly  improved  by  bowel  irrigation  and  drainage  subsequent 
to  appendicostomy  or  cecostomy.  In  2  cases  he  has  relieved  patients 
afflicted  with  epilepsy  from  recurrences  of  the  attack  for  periods  vary- 
ing from  eight  weeks  to  six  months.  He  has  also  convinced  himself 
that  predigested  and  other  foods  employed  in  artificial  feeding  are 
absorbed  more  quickly  and  in  larger  amounts  when  projected  into  the 
colon  through  an  appendiceal  or  cecal  opening  than  when  introduced 


548      SURGICAL    TREATMENT    OF    THE    GASTRO-INTESTINAL    TR.\CT 

by  way  of  the  rectum,  and  the  same  may  be  said  of  a  saline  solution 
employed  in  large  quantities,  or  the  drop  method  to  relieve  peritonitis, 
shock,  etc. 

Appendicostomy  and  cecostomy  are  beneficial  in  man\-  ways  be- 
cause through  their  aid  one  can  reach  with  hot  or  cold  water,  saline, 
or  medicated  solutions  or  oils  all  parts  of  the  diseased  and  healthy 
bowel,  and  thereby  dislodge  irritating  foreign  bodies,  food,  and  feces, 
wash  out  bacteria,  toxins,  and  foul  discharges,  heal  ulcers,  minimize 
auto-intoxication,  diminish  or  stimulate  peristalsis,  arrest  colic  and 
pain,  soothe  the  inflamed  mucosa,  nourish  debilitated  patients,  pre- 
vent or  relieve  gas  distention  and  fecal  impaction,  increase  the  cir- 
culating media,  and  rapidly  diminish  the  number  of  evacuations  of 
individuals  afiflicted  with  chronic  diarrhea. 

These  procedures  are  also  effective  in  that  they  improve  the  psychic 
state  of  the  patient,  who  is  impressed  by  the  operation,  and  believes 
that  at  last  a  plan  of  treatment  has  been  adopted  which  will  lead  to  his 
permanent  cure. 

Irrigation  from  below  would  prove  as  effective  as  that  practised 
through  an  artificial  opening  in  the  appendix  or  cecum  were  it  not 
for  the  fact  that  the  solution,  or  tube  throtigh  which  it  is  to  pass,  is 
usually  blocked  by  the  anal  sphincter,  rectal  valves,  0' Beimels  sphincter, 
or  a  sharp  bend  in  the  bowel  at  the  rectosigmoid  juncture.  Certainly 
.r-ray  bismuth  photographs  (see  Fig.  127)  demonstrate  clearly  that 
a  colon-tube  seldom  if  ever  passes  through  the  sigmoid  flexure.  Much 
of  the  benefit  derived  from  direct  bowel  treatment  or  through-and- 
through  irrigation  is  due  to  the  mechanic  action  of  the  fluid  cleansing 
the  mucosa  of  irritating  discharges,  bacteria,  toxins,  and  feces,  but  the 
usefulness  of  the  solution  can  be  enhanced  by  the  addition  of  antiseptic 
and  stimulating  medicaments  which  should  be  used  in  greater  amounts 
at  the  beginning,  and  then  gradually  reduced  as  the  ulcers  heal  and 
the  evacuations  diminish  in  frequency. 

In  neglected  cases  complicated  by  extensive  ulceration,  repeated 
hemorrhages,  persistent  diarrhea,  and  distressing  auto-intoxication, 
irrigation  should  be  immediately  employed  two  or  three  times  daily. 
Under  such  circumstances  the  author  begins  with  a  solution  of  silver 
nitrate,  gr.  30  to  the  quart  (2.0-1000.0),  after  w'hich  the  bowel  is 
washed  out  with  a  normal  saline  solution  to  get  rid  of  any  excess  of 
silver.  The  strength  of  the  solution  is  diminished  daily  until  the 
diarrhea  is  greatly  improved,  when  one  of  the  irrigants  mentioned 
below  are  substituted  for  the  silver.  When  the  stools  are  very  offen- 
sive the  odor  and  irritation  incident  to  them  can  be  eradicated  by 
flushing  the  colon  once  or,  if  need  be,  twice  daily  w'ith  a  5  per  cent, 
ichthyol  or  25  per  cent,  hydrogen  peroxid  solution. 

In  cases  of  moderate  diarrhea,  which  indicates  that  the  bowel  is 
not  highly  inflamed  or  extensively  ulcerated,  a  cure  can  usualK"  be 
accomplished  by  irrigating  the  colon  daily  with  a  4  per  cent,  boric 
acid.  2  per  cent,  ichthyol,  3  per  cent,  balsam  of  Peru,  2  per  cent,  per- 
manganate, or  5   per  cent,   argyrol   solution,  or   the  following  com- 


GENER.\L    REMARKS  549 

bination.  which  has  universally  proved  satisfactory  in   the  author's 
hands : 

I^     Fl.  ext.  krameria giv  (120.0J; 

Bicarbonate  of  soda 3ij  (8.0). — M. 

Sig. — One  or  two  tablespoonsful  to  a  quart  of  warm  water  and  irrigate  the  colon 
three  times  weekly. 

Salts  of  qiiinin  (particularly  the  bisulphate),  extensively  employed 
in  tropical  countries  in  the  irrigating  treatment  of  entambeic  and 
bacillary  colitis  (dysentery),  do  not  possess  specific  properties  superior 
to  the  solutions  above  mentioned  in  these  or  other  types  of  ulcerative 
colitis,  and  their  beneficial  effect  is  due  mainly  to  the  cleansing  and 
healing  qualities  of  the  solution.  The  quinin  should  be  dissolved  in 
dilute  sulphuric  acid,  and  enough  of  the  solution  added  to  the  water 
to  make  a  i  :  1000  solution,  which  is  employed  in  the  same  \\3X  and 
amounts  as  other  irrigants. 

Hot  solutions  (110°  F.)  are  soothing,  and  are  indicated  when  the 
bowel  is  sore  or  irritable,  and  when  the  patient  complains  of  pain, 
cramps,  or  enterospasm,  while  cold  (65°  F.),  except  to  diminish  the 
temperature,  are  objectionable,  because  they  cause  the  intestine  to 
contract  and  expel  the  fluid  before  it  has  accomplished  its  purpose, 
induce  cramps,  and  chill  the  patient. 

Tuttle  claims  that  ice-water  irrigation  destroys  ameba?  and  is  a 
specific  for  amebic  colitis,  but  the  author's  experience  with  ice-water 
has  not  been  satisfactory  in  this  class  of  cases.  Cold-water  irrigation 
undoubtedly  attenuates  amebs  and  relieves  the  diarrhea,  but  relapses 
often  occur  when  cold  colonoclysis  is  suspended,  because  buried  enta- 
mebae  work  to  the  surface  of  the  mucosa  and  reinfect  it.  The  author 
prefers  the  irrigants  already  recommended  because  they  are  equally  if 
not  more  elTective  than  ice-water,  and  because  the  latter  shocks  and 
chills  the  patient,  causes  intense  cramps,  and  is  retained  but  a  short 
time.  On  the  other  hand,  the  warm  medicated  oils  and  solutions  em- 
ployed by  the  author  both  attenuate  or  destroy  the  amebse  or  other  in- 
fective agents  causing  colitis,  and  through  the  contained  heat  soothe 
the  sensitive  mucosa  and  arrest  pain  and  enterospasm.  In  all  forms  of 
ulcerative  colitis  the  strength  of  the  solution  and  the  frequency  with 
which  it  is  employed  is  regulated  by  the  degree  of  diarrhea.  This  class 
of  patients,  though  apparently  cured,  should  be  warned  that  colitis 
may  recur  if  they  are  indiscrete  in  their  manner  of  living  or  remain  in 
a  community  where  the  infectious  forms  of  diarrhea  are  endemic.  In- 
testinal stasis  from  atonic  constipation  or  bowel  blocking  can  be  fore- 
stalled by  appendicostomy  or  cecostomy  and  colonochsis,  but  usually 
returns  when  the  irrigations  are  stopped. 

Sometimes  the  bowel  is  very  sensitive  and  resents  the  introduction 
of  fluids,  in  which  case,  and  when  cramps  and  enterospasm  are  a 
frequent  complication,  a  few  ounces  of  warm  liquid  parafifin,  mineral, 
olive,  or  cotton  seed  oil  should  be  substituted  for  or  alternated  with 
the  medicated  irrigations.    Oil,  when  introduced  into  the  colon  or  sig- 


550      SURGICAL    TREATMENT    OF    THE    GASTRO-INTESTINAL    TRACT 

moid  from  above  or  below  while  the  patient  is  in  the  inverted  posture 
(see  Fig.  122),  usually  remains  in  the  bowel  for  several  hours,  par- 
ticularly when  it  contains  a  slight  amount  of  bismuth,  because  of  its 
soothing  and  healing  effect  upon  the  sensitive  mucosa. 

As  a  rule,  not  more  than  a  quart  of  the  irrigating  solution  is  re- 
quired, but  in  aggravated  cases,  when  the  bowel  is  filled  with  dis- 
charges, irritating  feces,  and  debris,  it  is  advisable  to  employ  a  half- 
gallon  or  more  for  the  first  few  treatments  or  until  a  smaller  amount 
thoroughly  cleanses  the  colon. 

Sometimes  patients  fail  to  recover  following  appendicostomy  and 
cecostomy,  owing  to  the  fact  that  the  irrigations  are  always  carried 
out  while  the  patient  is  in  the  same  posture.  The  subject  should  be 
requested  to  frequently  change  his  position  during  the  flushings,  so 
that  all  parts  of  the  diseased  mucosa  may  be  reached,  otherwise  un- 
healthy areas  will  remain  untouched  and  relapses  will  follow. 

When  through-and-through  irrigation  has  been  carefully  practised 
for  weeks,  and  does  not  completely  arrest  the  diarrhea  (which  indicates 
healing  of  the  inflamed  and  ulcerated  mucosa),  the  stomach  and  other 
organs  should  be  examined  to  see  if  there  is  not  some  other  complicating 
disease  or  an  intestinal  obstruction  which  is  interfering  with  the 
treatment. 

Closure  of  the  Opening. — The  appendiceal  or  cecal  vent  should  not 
be  closed  in  moderate  cases  of  ulcerativ^e  colitis  under  three  months, 
and  in  neglected  cases  (particularly  those  due  to  entamebic  or  tubercular 
colitis,  etc.)  it  should  be  left  open  as  a  precautionary  measure  for  half 
a  year  or  longer,  even  when  the  patient  is  apparently  cured,  because 
otherwise  the  ulceration  and  diarrhea  may  recur,  owing  to  renewed 
activity  of  buried  infective  agents  which  are  slow  in  gaining  the  surface 
of  the  mucosa.  Individuals  who  live  in  tropical  countries  where 
dysenteric  diarrhea  is  endemic  are  safer  when  the  opening  is  not 
closed  at  all,  because  they  may  become  infected  at  any  time  while  there. 

Usually  an  appendiceal  opening  spontaneously  closes  following 
withdrawal  of  the  catheter  or  the  author's  appendiceal  irrigator  and 
stopping  of  the  irrigation,  but  when  it  does  not,  cauterization  of  its 
mucous  lining  with  a  silver  or  copper  stick,  or  an  electric  or  Paquelin 
cautery  tip,  facilitates  the  process.  On  seven  occasions,  when  these 
procedures  failed,  the  tissues  were  infiltrated  with  a  |  per  cent,  eucain 
solution,  the  appendix  was  dissected  free  down  to  its  cecal  attachment, 
ligated,  excised,  and  the  wound  closed  with  catgut  without  entering  the 
peritoneal  cavity. 

Cecostomy  openinos  are  always  difficult  to  close  when  the  cecum 
has  been  anchored  to  the  skin,  as  in  Gibson's  operation  (see  Fig.  154), 
but  when  the  bowel  has  been  attached  to  the  inner  abdominal  parietes 
and  a  rubber  tube  is  left  projecting  from  it  through  the  integument 
(Figs.  150,  151),  spontaneous  closure  of  the  opening  quickly  follows 
withdrawal  of  the  catheter  because  the  wound  closes  down  from  above 
and  blocks  the  aperture  in  the  intestine.  When  healing  is  delayed  the 
mucosa  lining  the  fistula  should  be  cauterized  or  removed. 


APPEXDICOCECOSTOMV 


551 


Where  less  radical  measures  fail,  the  abdomen  should  be  opened 
under  local  or  general  anesthesia,  the  cecum  freed  from  its  attachments, 
and  the  opening  in  its  wall  inverted  and  buried  by  infolding  Lembert 
sutures  if  it  is  large,  or  purse-string  sutures  if  it  is  small.    There  is  less 


Fig.  150. — Right  way  of  performing 
cecostomy.  Note  that  the  catheter  is  car- 
ried through  the  abdominal  wall  to  the 
cecum  and  anchored  to  the  inner  parietes. 
After  this  operation  closure  of  the  opening 
generally  follows  removal  of  the  catheter 
and  cauterization. 


Fig.  151. — Wrong  way  of  performing 
cecostomy.  Note  that  the  cecum  is  at- 
tached to  the  skin.  Closure  of  the  opening 
after  this  procedure  requires  a  second  and 
perhaps  serious  abdominal  operation. 


danger  of  leakage  and  peritonitis  after  the  operation  when  the  cecum  is 
attached  to  the  parietal  peritoneum  before  the  wound  is  closed.  The 
author  does  not  know  of  an  instance  when  the  appendiceal  or  cecal 
opening  has  failed  to  close  when  handled  in  the  above  manner. 


Fig.  152. — Appendicocecostoray  show- 
ing catheter  introduced  through  the  ap- 
pendiceal stump. 


Fig.  153. — Appendicocecostomy  show- 
ing catheter  introduced  through  the  in- 
verted appendiceal  stump. 


Appendicocecostomy. — This  name  is  employed  to  indicate  an 
operation  wherein  a  catheter  is  introduced  through  the  appendiceal 
stump  into  the  cecum  to  facilitate  through-and-through  irrigation,  and 
in  cases  where  appendicostom\-  proves  impractical  because  the  appen- 


552       SURGICAL    TREATMENT    OF    THE    GASTRO-INTESTINAL    TRACT 

dix  is  diseased,  strictured,  too  short,  or  otherwise  unfit  for  the  purpose. 
Both  appendicostomy  and  cecostomy  should  take  precedence  over 
appendicocecostomy,  which  is  seldom  performed.  A  few  surgeons 
favor  the  procedure  because  it  provides  a  means  of  direct  bowel  treat- 
ment, and  at  the  same  time  eliminates  the  appendix,  which  might  cause 
future  trouble  (Figs.  152,  153). 

Enterostomy  is  rarely  employed  in  the  treatment  of  inflammatory, 
ulcerative,  and  parasitic  affections  of  the  alimentary  tract  because 
these  types  of  disease  are  usually  located  in  the  colon,  fluid  feces  al- 
most constantly  dribble  through  the  opening  to  irritate  the  skin,  and 
a  serious  operation  is  required  after  a  cure  has  been  accomplished  to 
close  the  artificial  opening. 

Colostomy  was  occasionally  resorted  to  in  the  surgical  treatment  of 
diarrhea  and  colitis  before  the  advent  of  appendicostomy  and  cecos- 
tomy, but  since  the  operation  has  become  obsolete  because  it  is  not 
so  effective.  Patients  strongly  object  to  having  bowel  movements 
through  their  side,  and  a  prolonged  and  dangerous  operation  is  re- 
quired to  re-establish  continuity  of  the  intestine  when  the  treatment 
has  been  successful. 

Results  of  Through-and-through  Irrigating  Treatment  Following 
Appendicostomy  and  Cecostomy. — The  author  has  treated  200  cases 
of  diarrhea  induced  by  chronic  catarrhal,  tubercular,  bacillary,  enta- 
mebic,  balantidic,  syphilitic,  helminthic  and  gonorrheal  colitis,  intes- 
tinal obstruction,  or  other  bowel  affections  by  irrigation  subsequent 
to  appendicostomy,  cecostomy,  appendicocecostomy,  appendico-enter- 
ocecostomy,  and  colostomy,  alone  or  in  conjunction  with  other  oper- 
ations, and  nearly  all  patients  were  improved. 

The  vast  majority  were  permanently  cured,  a  considerable  number 
had  one  or  more  relapses  after  remaining  well  for  weeks,  months,  or 
years,  and  a  few  were  benefited  only  for  a  few  days  or  weeks,  and  then 
relapsed  into  their  former  deplorable  state. 

In  the  most  unfavorable  cases  direct  bowel  treatment  usually 
improves  the  manifestations  of  auto-intoxication,  arrests  bleeding,  di- 
minishes the  amount  of  discharges,  increases  the  number  of  red  blood- 
cells,  deodorizes  the  stools,  decreases  the  formation  of  gas,  lessens  the 
number  of  evacuations,  and  allays  cramp,  enterospasm,  tenesmus, 
and  burning  in  the  rectum,  but  for  one  reason  or  another  fails  to  effect 
a  cure.  Perfect  results  are  not  to  be  expected  in  tubercular  colitis 
complicated  by  phthisis,  dysenteric  ulceration,  where  the  mucosa  has 
been  extensively  destroyed,  the  patient  has  a  liver  abscess  or  general 
infection,  in  stricture,  cancer,  polyposis,  or  papillomata  of  the  bowel 
(unless  the  stricture  or  growth  has  been  corrected  or  removed),  when 
the  local  is  complicated  by  general  or  disease  in  other  organs,  and  when 
patients  indulge  freely  in  alcoholics,  dietary  indiscretions,  violent  exer- 
cise, worry  over  business  affairs,  or  fail  to  carry  out  the  irrigations  and 
treatment  as  directed. 

Convalescence  is  more  rapid  when  this  class  of  sufferers  are  placed 
amid  pleasant  surroundings,  are  permitted  to  eat  freely  of  nourishing 


RESULTS    OF    THROUGH-AND-THROUGH    IRRIGATING    TRKATMKXT      553 

food  which  agrees  with  them,  and  indulge  in  moderate  exercise  (except 
during  crises),  when  general  or  ner\-e  tonics  which  do  not  upset  the 
stomach  or  intestine  are  administered  to  upbuild  their  general  health, 
and  when  potassium  and  mercury  are  added  to  the  treatment  where  the 
diarrhea  is  secondary  to  luetic  colitis.  A  complete  cure  seldom  occurs 
where  the  bowel  is  partially  blocked  by  ptosis,  invagination,  adhesions, 
a  twist  or  angulation,  or  extra-intestinal  pressure,  unless  the  lesion  is 
corrected  or  extirpated  at  the  time  the  appendix  or  cecum  is  opened 
for  drainage  and  irrigation. 

Sometimes  myxorrhea  membranacea  and  colica  respond  promptly 
to  this  method  of  treatment,  and  again  do  not,  possibly  because  the 
condition  is  dominated  by  a  ner\ous  element  or  a  gastrogenic  or  entero- 
genic  dyspepsia. 

Curl,  who  employed  appendicostomy  in  22  Isthmian  laborers 
afflicted  with  entamebic  colitis,  says  that  the  immediate  results  were 
good  and  that  a  number  were  permanently  cured  (others  he  could  not 
trace).  Pettyjohn's  3  patients  with  amebiasis  were  discharged  cured 
and  without  amebae  in  the  stools  a  few  weeks  after  appendicostomy. 
In  his  report  on  the  operation  in  this  form  of  dysenten,-  he  holds  that 
deaths  following  the  operation  are  not  due  to  it,  but  to  ravages  of 
the  disease.  Tuttle,  the  author,  and  others  have  recorded  a  large 
number  of  cases  of  amebiasis  cured  by  appendicostomy  or  cecos- 
tomy  and  irrigation,  and  death  has  seldom  resulted  from  surgical 
intervention. 

The  mortality  following  appendicostomy  and  cecostomy  is  about 
the  same  as  for  the  interval  operation  for  appendicitis  or  colostomy. 
The  actual  mortality  of  the  operations  of  appendicostomy  and  cecos- 
tomy in  the  author's  200  cases  has  been  2  per  cent.,  he  having  lost  2 
patients  from  each  of  these  procedures. 

There  were  8  or  10  deaths  shortly  following  the  operation,  but  in 
some  death  was  due  to  the  disease  from  which  the  patient  suffered 
or  concurrent  ailments;  in  others  to  resection,  intestinal  exclusion, 
colopexy,  etc.,  where  drainage  was  pro\"ided  by  way  of  the  appendix 
or  cecum,  and  in  still  others  to  the  almost  moribund  state  of  the 
sufferer  at  the  time  of  operation. 

One  patient,  upon  whom  appendicostomy  and  sigmoidopexy  were 
performed,  died  from  peritonitis  caused  by  an  assistant  who  mistook 
an  aperture  at  the  side  for  the  appendiceal  opening  and  injected  the 
irrigating  fluid  directly  into  the  peritoneal  cavity.  A  second  died  a?  a 
result  of  sloughing  of  the  cecum  about  the  appendiceal  attachment, 
in  consequence  of  heavy  tension  upon  the  appendix  caused  by  a  fecal 
impaction  and  gas  retention  in  the  caput  coli.  One  cecostomy  ter- 
minated fatally  from  peritonitis  caused  by  the  escape  of  liquid  and  pus 
into  the  abdomen  during  the  operation,  and  a  second  patient,  upon 
whom  cecostomy  was  performed,  died  as  a  result  of  a  large  slough  in 
the  anterior  cecal  wall  about  the  catheter,  apparently  caused  by 
four  infolding  purse-strings  sutures  which  had  been  placed  too  far 
apart. 


554      SURGICAL    TREATMENT    OF    THE    GASTRO-INTESTIXAL    TRACT 

Thus  far  the  author  has  not  had  a  death  from  his  cecostomy,  and 
does  not  see  why  the  mortality  from  it  should  be  higher  than  that  of 
ordinary  cecostomy. 

The  most  common  complications  of  appendicostomy  are  stitch- 
abscesses,  sloughing  of  the  organ,  tendency  of  the  appendiceal  opening 
to  close,  retraction  of  the  stump  beneath  the  skin,  tension  pain  when 
the  cecum  is  distended,  ulceration  of  the  mucosa,  and  discomfort  in- 
cident to  the  retained  catheter.  In  one  instance  a  hernia  occurred  at 
the  side  of  the  appendix,  and  in  another  case,  where,  after  a  cure,  the 
appendiceal  stump  was  left  in  situ,  the  patient  had  an  attack  of  appen- 
dicitis which  was  relieved  by  ordinary  appendectomy. 

Following  cecostomy  slight  infection  of  the  suture  line  is  quite  com- 
mon, owing  to  soiling  of  the  wound  by  the  feces  during  or  subsequent  to 
the  operation,  but,  except  in  rare  instances,  the  breaking  down  is 
confined  to  the  skin,  though  on  two  occasions  all  structures  separated 
down  to  the  transversalis  fascia,  and  two  months  were  required  to 
heal  the  wound. 

Frequently  the  integument  becomes  irritated  or  granulations  form 
around  the  opening,  conditions  quickly  relieved  by  a  6  per  cent,  silver 
nitrate  application. 

Occasionally  catheters  leading  to  the  cecum  get  soiled  or  hard, 
cause  considerable  discomfort,  and  require  changing. 

Much  of  the  annoyance  incident  to  the  escape  of  the  fecal  discharge 
can  be  avoided  by  clamping  the  catheter  with  a  cravat  clamp  and  firmly 
fixing  the  tube  with  narrow  adhesive  strips,  which,  after  being  made  to 
surround  it,  are  attached  on  all  sides  to  the  skin. 

When  the  appendiceal  or  cecal  opening  tends  to  remain  patent  the 
catheter  may  be  left  out  on  alternate  days  or  all  the  time,  but  in  either 
case,  when  the  aperture  is  inclined  to  close,  it  should  be  dilated  with 
graduated  catheters  or  forceps. 

Technic  of  Cecostomy. — In  the  original  direct  or  through-and- 
through  irrigating  method  of  treating  catarrhal  and  infectious  colitis 
causing  diarrhea  an  artificial  anus  was  established — a  procedure  which 
could  rightly  be  called  cecostomy.  In  the  light  of  our  present  knowledge, 
however,  the  operation  should  be  designated  as  colostomy,  since  the 
evacuations  take  place  through  the  side  and  the  bowel  is  put  at  rest, 
but  at  present  the  term  "cecostomy"  is  reserved  for  operations  where 
a  small  controllable  opening  is  made  in  the  cecum  through  which  the 
colon  can  be  irrigated  at  will — a  procedure  which  does  not  possess  the 
disgusting  features  of  an  artificial  anus. 

Gibson  in  1901^  described  his  valvular  cecostomy  (a  great  improve- 
ment over  right-sided  colostomy),  which  has  proved  useful  in  the  treat- 
ment of  inflammatory  and  ulcerative  lesions  of  the  colon,  sigmoid 
flexure,  and  rectum.  Briefly  described,  the  steps  of  the  operation  are 
as  follows: 

First  Step. — The  cecum  is  exposed  by  a  short  intermuscular  incision. 

Second  Step. — An  opening  is  made  in  the  anterior  surface  of  the 
'  Med.  Record,  vol.  i,  p.  405. 


TECHNIC    OF    CHCOSTOMV 


555 


cecum  through  the  longitudinal  band  and  a  medium-sized  catheter  is 
inserted. 

Third  Step. — Two  or  three  tiers  of  infolding  sutures  are  then  intro- 
duced at  the  sides  of  the  catheter  and  tied,  which  causes  the  cecal  wall 
to  project  inward  and  ioriw  a  valve  which  f)artiall\-  prevents  subsequent 
leakage  (Fig.  154J. 


Fig.  154. — Method  of  placing  tiie  infolding  sutures  in  Gibson's  cecostomy.     Note  that 
there  is  nothing  to  prevent  leakage  on  two  sides  of  the  catheter. 


Fourth  Step. — The  outer  sutures,  ha\"ing  been  left  long,  are  carried 
through  the  abdominal  wall  to  close  it  and  to  fix  the  cecum  to  the 
inner  parietes. 

The  catheter  is  left  in  for  a  few  days;  then  it  is  removed  and  re- 
introduced if  further  irrigation  is  required.  The  operation  is  fairly 
successful,  the  main  objection  being  the  leakage  which  takes  place 
in  some  cases. 


CHAPTER   LI 

SURGICAL  TREATMENT  OF  DIARRHEAL,  INFLAMMATORY, 
OBSTRUCTIVE,  AND  PARASITIC  DISEASES  OF  THE 
GASTRO-INTESTINAL   TRACT    {Continued) 

TECHNIC  OF  GANT'S  ENTEROCECOSTOMY  (CECOSTOMY),  APPENDI- 
COSTOMY,  APPENDICOCECOSTOMY,  AND  APPENDICO-ENTERO- 
CECOSTOMY 

Gant's  Cecostomy  with  an  Arrangement  for  Irrigating  the  Small 
Intestine  and  Colon. — The  author  will  now  describe  an  original  cecos- 
tomy^ (Fig-  155)  which  provides  a  means  of  separately  or  simulta- 
neously flushing  the  small  and  large  intestine,  a  procedure  to  which, 
for  want  of  a  better  name,  he  has  given  the  above  caption.  He  at  first 
termed  the  operation  ceco-enterostomy,  but  this  designation  proved 
unsatisfactory^  because  it  conveyed  the  idea  of  an  artificial  opening 
established  by  anastomosing  the  cecum  with  the  small  bowel,  when,  in 
reality,  the  communication  between  the  caput  coli  and  ileum  is  byway 
of  Bauhin's  (ileocecal)  valve.  Valvular  ceco-enterostomy  and  ileoceco- 
enterostomy,  also  considered,  were  finally  abandoned  as  confusing  in 
favor  of  the  appellation  cecostomy  with  an  arrangement  for  irrigating 
the  small  intestine  and  colon,  which  gives  one  a  fair  idea  of  the  nature 
of  the  operation  and  what  it  is  intended  to  accomplish. 

This  procedure  \vas  worked  out  with  the  object  of  providing  a 
method  of  flushing  the  colon  and  small  intestine,  the  author  having 
obser\'ed  that  appendicostomy  and  ordinary  cecostomy,  reinforced  by 
irrigation,  failed  to  cure  many  cases  of  chronic  diarrhea  induced  by 
catarrhal  and  the  various  types  of  infectious  colitis.  The  reason  for 
this  was  that  the  colon  and  small  bowel  were  involved  to  a  greater  or 
less  extent,  and  in  consequence  the  solution,  when  introduced  through 
an  artificial  opening  in  the  appendix  or  cecum,  failed  to  reach  the  dis- 
eased mucosa  above  the  ileocecal  valve.  That  such  a  condition  existed 
was  proved  by  the  fact  that  in  many  cases  a  cure  followed  the  author's 
cecostomy  and  bowel  flushing  after  appendicostomy  or  cecostomy  and 
irrigation  had  been  tried  without  success. 

Tuberculosis,  intestinal  syphilis,  entamebic,  bacillary,  and  balan- 
tidic  colitis  are  usually  confined  to  the  colon,  but  now  and  then  attack 
the  ileocecal  valve  and  lower  ileum,  as  shown  by  some  of  the  author's 
specimens.  Under  these  circumstances  reinfection  of  the  colon  after 
a  cure  will  surely  occur  unless  all  diseased  areas  in  the  mucosa  are 

'The  author  first  described  his  "Cecostomy"  in  a  paper  read  before  the  Medical 
Association  of  Greater  Xew  York,  which  was  pubHshed  in  the  Xew  York  Med.  Jour., 
August  15,  1908:  but  the  operation  had  been  performed  several  times  at  the  Post-Graduate 
Hospital  and  in  his  ])rivate  sanitarium  one,  two.  and  three  years  before. 

556 


GAXT  S    CECOSTOMV 


557 


treated  and  tlie  infecting  agents  (tubercle  bacilli.  entameba\  Balan- 
tidium  coli,  Shiga  bacilli,  etc.)  arc  destroyed.  This  can  onW  be  ac- 
complished through  the  author's  procedure  outlined  below. 

The  following  briefly  described  steps  of  the  author's  cecostomy  can 
be  readily  grasped  by  a  glance  at  the  accompanying  illustrations. 

First  Step. — Through  a  2-inch  intermuscular  (or  rectus)  incision, 
made  directly  o\er  the  cecum,  it  and  the  lowermost  part  of  the  ileum 


Fig.  155. — First  steps  in  Gant's  older  cecostomy  with  an  arrangement  for  irrij^ating 
the  small  intestine:  .\,  Catheter  bein^  introduced  through  the  cecum  into  the  small  bowel*, 
B,  catheter  guide  iu  silu  through  which  it  passes;  C,  C,  intestinal  clamps;  D,  side  view 
of  catheter  guide;  E,  obturator  from  the  same;  F,  purse-string  sutures. 

are  withdrawn  and  the  edges  of  the  wound  protected  by  gauze  hand- 
kerchiefs. 

Second  Step. — The  anterior  surface  of  the  cecum  is  scarified,  after 
the  ascending  colon  and  ileum  ha\e  been  clamped,  to  pre\ent  soiling 
of  the  wound  when  the  bowel  is  opened  (Fig.  155,  C). 

Third  Step. — Two  or  more  linen  seromuscular  purse-string  sutures 
are  placed  in  the  anterior  wall  of  the  cecum  opposite  the  ileocecal  vaKe 
(Fig.  155,  F)  and  the  bowel  is  opened  inside  the  suture  line. 


558      SURGICAL    TREATMENT    OF    THE    GASTRO-IXTESTIXAL    TRACT 

Fourth  Step. — The  gut  is  grasped  at  the  juncture  of  the  large  and 
small  intestine  and  held  in  such  a  way  that  the  ileocecal  valve  rests 
between  the  thumb  and  fingers  of  the  left  hand  (Fig.  155).     A  Gant 


Cf^AVAT  CLAMP 


Fig.  156. — Gant's  older  cecostomy.  showing  catheters  in  position  through  which  the 
small  and  large  intestines  can  be  irrigated  singly  or  simultaneously:  A,  A  and  B,  Adhesive 
strips  which  retain  the  catheters  in  position;  C,  C.  rubber  tubings  across  which  the  sus- 
pensory- sutures  are  tied;  F,  Circular  valve  formed  about  the  catheters  by  the  infolding 
purse-string  sutures.  The  drawing  in  lower  right-hand  comer  shows  location  of  cecal 
opening  and  method  of  introducing  the  suspensorj-  sutures  (C,  C). 

catheter  guide  (Fig.  155,  B,  D,  E)  is  then  passed  directly  across  the 
cecum  and  through  the  ileocecal  valve  into  the  small  intestine,  aided 
bv  the  thumb  and  finders. 


GANT  S    CECOSTOMY 


559 


Fifth  Step. — The  obturator  is  removed  from  the  guide  and  a 
catheter  is  introduced  into  the  small  bowel  (Fig.  155,  A)  and  held 
there  by  an  assistant  until  it  is  anchored  to  the  cecum  by  catgut  sutures 
to  prevent  its  slipping  out  l^'fore  the  operation  is  finished. 

Sixth  Step. — A  short  rubjjer  tube  3  inches  long  is  projecu-d  into  the 
cecum  for  an  inch  or  more  and  anchored  beside  the  one  projecting  into 
the  small  gut  (Fig.  156). 

Seventh  Step. — The  infolding  purse-string  sutures  are  tied,  forming 
a  cone-shaped  valve  (Fig.  156,  F)  about  the  catheters,  to  prevent  leak- 
age of  gas  and  feces. 

Eighth  Step. — After  removal  of  the  clamps  the  scarified  cecum  is 
anchored  to  the  transversalis  fascia,  denuded  of  its  peritoneum  by  two 
linen  suspension  sutures,  which  are  passed  through  the  abdominal  wall. 

Ninth  Step. — The  suspension 
sutures  are  tied  across  rubber 
tubing  (Fig.  156,  C),  the  wound 
closed  by  the  layer  method,  and 
the  catheters  fastened  by  stitch- 
ing or  by  encircling  them  with 
an  adhesive  strip  (Fig.  156,  B) 
to  hold  them  together.  This  is 
crossed  at  a  right  angle  with  a 
second  piece  of  plaster  placed  be- 
tween the  catheters  (Fig.  156,  A) 
to  prevent  their  slipping  out. 

Tenth  Step. — The  ends  of  the 
catheters  are  closed  with  cravat 
clamps  (Fig.  156)  to  prevent 
leakage,  and  the  operation  is 
completed  by  applying  the  dress- 
ings about  the  projecting  tubes. 

One  catheter  is  left  longer 
than  the  other,  or  is  identified 
in  some  way,  that  the  intern  or 

nurse  may  know  ivhich  is  in  the  large  and  ichich  in  the  small  intestine 
when  time  for  irrigation  arrives.  To  avoid  danger  from  infection 
treatment  is  not  begun  before  the  fifth  day,  except  when  diarrhea, 
hemorrhages,  or  mixed  infection  manifestations  are  alarming. 

The  catheters  may  be  quickly  changed  by  cutting  the  attached 
adhesive  strips  and  withdraw^ing  the  one  projecting  into  the  cecum. 
The  catheter  guide  is  then  passed  over  the  other  into  the  small  intes- 
tine, where  it  is  retained  until  the  old  tube  has  been  remo\ed  and  a  new 
one  introduced.  A  second  piece  of  catheter  is  then  placed  in  the  cecum 
and  both  are  prevented  from  slipping  out  by  adjusting  fresh  adhesive 
straps  after  the  manner  already  described,  and  replacing  the  cravat 
clamps  and  by  the  methods  shown  in  the  drawings  (Figs.  156,  157). 

Before  deciding  upon  the  above  technic  the  writer  irrigated  the 
small  intestine  by  passing  a  glass  or  silver  catheter  through  the  cecal 


Fig. 
circular 


157. — Method  of  introducinj^  the 
infolding  and  suspensory  sutures 
in  the  author's  cecostomy.  Here  a  circular 
valve  is  formed  about  the  catheter  which 
prevents  leakage  on  all  sides. 


560      SURGICAL    TREATMENT    OF    THE    GASTRO-IXTE5TIXAL    TRACT 

opening  and  into  the  small  gut  for  each  irrigation.  This  practice  was 
abandoned  as  impractical,  however,  because  of  the  ditiiculty  encoun- 
tered in  locating  and  passing  the  valve  each  time,  and,  further,  be- 
cause the  patient  could  not  irrigate  himself. 

The  writer  has  had  no  reason  to  suspect  that  peristalsis  has  forced 
the  catheter  out  of  the  small  intestine  except  in  his  first  cecostomy. 
where  the  tube  was  soft,  cut  short,  and  projected  only  one  inch  instead 
of  several  inches  beyond  the  ileocecal  valve.  He  feels  confident  that 
the  catheter  remained  in  the  small  gut  in  his  other  cases  because:  (a) 
water  was  more  quickly  evacuated  when  injected  through  the  colonic 
pipe  than  when  deposited  in  the  small  bowel ;  (b)  when  a  minute  quan- 
tity of  a  10  per  cent,  solution  of  methylene-blue  was  injected  into  the 
former  it  appeared  in  the  urine  sooner  than  when  introduced  into  the 
small  gut;  [c)  the  catheter  guide  could  be  carried  over  the  tube  in  the 


Fig.  158. — Author's  rubber  enterocolonic  irrigator:  A.  Bulb  used  to  distend  the  inflating 
bag;  B,  inflating  bag;  1.  tube  through  which  the  irrigating  fluid  passes  to  the  small  intes- 
tine; 2,  tube  connecting  with  the  cecal  opening  of  the  colonic  irrigator;  3,  inflating  tube. 
The  movable  hard-rubber  ring  is  used  to  measure  the  distance  to  the  ileocecal  valve,  which 
varies  in  different  indi\"iduab.    The  various  pipes  are  closed  by  cravat  clamps. 


small  intestine,  and  the  latter  could  be  remo^•ed  and  replaced  at  will; 
and,  further,  id  1  fluid  feces  could  be  withdrawn  more  often  through  the 
pipe  in  the  small  intestine  than  through  the  colonic  catheter. 

To  avoid  possible  expulsion  of  the  catheter  from  the  ileum  the 
writer,  on  different  occasions,  successfully  employed  catheters  made  of 
silk,  silver,  glass,  and  soft  rubber  reinforced  by  an  inner  tubing  of 
metal  or  hard  rubber,  which,  owing  to  their  non-flexibility,  could  not 
be  forced  out  of  the  bowel.  Only  that  portion  of  the  pipe  projecting 
into  the  small  bowel  was  reinforced,  as  the  rubber  catheter  induced 
but  little  irritation  because  of  its  softness  and  flexibility  and  ser\-ed 
the  desired  purpose. 


GANT  S    CECOSTOMY 


561 


To  facilitate  the  operation,  dispense  with  soft  catheters,  and  insure 
the  irrigating;  sokition  entering  and  remaining  as  long  as  desired  in  the 
small  bowel,  the  author  devised  an  enterocolonic  irrigator  (Fig.  158), 
which  he  exhibited  before  the  Cleveland  Academy  of  Medicine,  Novem- 
ber 19,  1909,  and  the  Medical  and  Chirurgical  F'aculty  of  Maryland 


l-'ig.  159. — Steps  showing  Gant's  newer  cecostomy,  where  the  nu'tal  enterocolonic 
irrigator  is  employed,  which  jirovides  for  irrigation  of  both  the  small  and  large  intestines: 
1,  Irrigator  in  ]K)sition:  A.  irrigating  tubes;  B,  inflating  attachment;  C,  cravat  clamp 
for  closing  same;  I),  inflating  bag  distended  with  air  to  prevent  return  of  the  solution 
into  the  colon;  E,  cover  for  irrigator;  F,  circular  valve  formed  above  the  irrigator  by 
jjurse-string  sutures  to  prevent  leakage;  2,  side  view  of  Gant's  metal  enterocolonic 
irrigator;  3,  front  and  sectional  view  of  same;  4,  celluloid  guide  emjiloycd  in  removing 
and  reintroducing  the  irrigator  for  cleansing  and  repairing  purposes. 


at  Baltimore,  April  27,  1910.'     The  irrigator,  which  lias  l)een  success- 
fully employed  in  a  considerable  number  of  cases  in  the  treatment  of 
inflammatory  and  ulcerative  lesions  of  the  small  intestine  and  colon, 
^  Interstate  Med.  Jour.,  vol.  xvii,  No.  19 10. 
36 


562   SURGICAL  TREATMENT  OF  THE  GASTRO-IXTESTINAL  TRACT 

or  both,  is  of  convenient  size,  made  of  hard  rubber  or  metal  (Figs. 
158,  159),  and  self-explanatory  when  studied  in  connection  with  the 
accompanying  illustrations. 

When  the  irrigator  is  in  position  the  inflating  bulb  (Fig.  159,  B) 
lies  in  the  small  intestine  at  or  near  the  ileocecal  valve  (Fig.  159,  D). 
When  distended  it  fills  the  bowel  and  prevents  escape  of  the  solution 
into  the  cecum,  thereby  enabling  the  attendant  accurately  to  gauge  the 
amount  of  fluid  deposited  in  the  small  bowel  and  to  retain  it  there  as 
long  as  required.  By  means  of  this  twin-tube  irrigator  the  small  and 
large  intestines  can  be  quickly  and  scientifically  flushed,  singly  or 
together,  by  the  physician,  nurse,  or  patient. 

The  steps  in  the  writer's  cecostomy  when  the  irrigator  is  em- 
ployed are  similar  to  those  already  described  when  catheters  are  used 
(see  Figs.  155, 156),  except  that  the  Gant  catheter  guide  is  unnecessary 
and  the  apparatus  is  retained  in  position  by  attached  pieces  of  tape 
which  encircle  the  body,  or  by  adhesive  strips. 

Indications  for  the  Author's  Cecostomy. — In  a  paper  read  before 
the  Medical  Association  of  Greater  New  York,  April  30,  1908,  and 
since,  the  author  has  called  attention  to  the  fact  that  his  cecostomy  is 
indicated  in  the  treatment  of  intestinal  parasites,  enteritis,  enteroco- 
litis, peritonitis,  paralytic  ileus,  intussusception,  catarrhal,  tubercu- 
lous, syphilitic,  dysenteric,  and  gonorrheal  colitis,  ordinary  and  per- 
nicious anemia;  in  the  many  manifestations  dependent  upon  intestinal 
auto-intoxication,  ptomain-poisoning,  diarrhea  of  adults  and  children, 
intestinal  feeding,  malnutrition,  and  following  operations  upon  the 
mouth,  throat,  esophagus  or  stomach,  in  gastric  stricture,  ulcer,  cancer, 
and  other  disturbances  where  rest  of  the  organ  and  artificial  feeding  is 
required.  Again,  he  has  claimed  that  by  means  of  his  cecostomy 
various  intestinal  diseases  could  be  investigated  to  determine  the 
amount  and  nature  of  the  intestinal  juices  and  discharges,  the  charac- 
ter of  the  feces,  the  action  of  salines  and  other  cathartics  injected 
directly  into  the  small  and  large  bowels,  the  marked  immediate  vaso- 
motor effect  following  hot  and  cold  enteroclysis,  the  introduction  of 
bacteria  for  therapeutic  purposes,  the  injection  of  a  bismuth  solution 
into  the  intestine  for  .x-ray  diagnosis,  and  in  the  study  of  many  other 
interesting  problems. 

In  closing  the  discussion  of  the  above-mentioned  paper  the  author 
reported  several  cases  successfully  treated  by  his  operation,  and  stated 
that,  while  he  had  not  had  experience  with  it  in  the  treatment  of  cholera 
and  typhoid  fever,  he  believed  it  was  indicated,  and  in  future  would  be 
used  in  the  treatment  of  these  and  nearly  if  not  all  other  non-obstruct- 
ing diseases  of  the  small  and  large  bowels  complicated  by  diarrhea, 
hemorrhages,  or  toxemia. 

In  his  work  on  "Constipation  and  Intestinal  Obstruction,"  pub- 
lished in  January,  1909,  the  author  pointed  out  the  advantage  of 
cecostomy  as  a  means  of  drainage  when  the  cecum  or  another  part  of 
the  colon  was  excluded.  He  has  also  on  several  occasions  employed 
his  cecostomy  when  operating   for   mechanic  constipation   alone  or 


COMMENTS 


563 


when  complicated  by  colitis,  as  well  as  in  the  i)alliative  treatment  of 
obstipation  where  the  patient  declined  to  have  the  obstruction  cor- 
rected or  removed,  >et  suffered  from  deplorable  auto-intoxication  or 
recurring  impaction. 

The  author  l)elieves  his  cecostomy  to  be  superior  to  that  of  Gibson 
because,  while  eciually  simple  in  technic,  the  operation  recjuires  no  more 
time,  there  is  less  leakage  owing  to  the  purse-string  infolding  being 
substituted  for  his  lateral  valvular  sutures,  both  the  small  and  large 
bowel  can  be  irrigated  by  the  attendant  or  patient  separately  or  at  the 
same  time,  a  hrmer  union  is  obtained  by  attaching  the  cecum  to  the 
transversalis  fascia  than  to  the  parietal  peritoneum,  and  the  opening 
heals  spontaneously  after  the  cath- 
eters are  removed. 

Comments. — Another  method 
often  employed  by  the  WTiter  to 
prevent  leakage  in  ordinary  cecos- 
tomy is  to  bury  about  an  inch  of 
the  catheter  in  the  cecal  wall  by 
whipping  the  gut  over  it  from  the 
opening  outward  (Fig.  160)  with  a 
continuous  or  interrupted  Lembert 
suture. 

To  diminish  the  danger  of  leak- 
age, peritonitis,  and  sloughing  the 
opening  about  the  tube,  catheter, 
or  irrigator  should  be  made  as 
small  as  possible,  and  unnecessary 
stitching  in  the  cecum  should  be 
avoided. 

In  a  case  of  the  author's  a  segment  of  the  cecum  w'as  caught  in  the 
wound  when  closed,  and  in  consequence  the  patient  suffered  terribly 
from  nausea  and  vomiting  until  the  abdomen  w'as  opened  and  it  was 
released. 

During  a  cecostomy  operation  the  catheter  or  irrigator,  following 
its  introduction  into  the  cecum  or  small  intestine,  should  be  held 
firmly  in  place  until  anchored,  for  in  one  of  the  author's  cases  a  careless 
assistant  withdrew  the  tube  as  the  wound  was  being  closed,  necessi- 
tating a  repetition  of  the  operation. 

Soiling  of  the  wound  can  be  prevented  in  a  large  measure  In"  clamp- 
ing the  ileum  and  cecum,  and  not  opening  the  latter  until  after  the 
suspension  and  purse-string  sutures  have  been  introduced.  One  can 
readily  incise  the  intestinal  musculature  wuth  a  knife,  but  the  mucosa 
recedes  upon  pressure,  and  to  avoid  delay  and  prevent  e\ersion  ot  the 
mucous  membrane  later  on  the  author  seizes  it  with  mouth-toothed 
forceps  and  removes  a  small  section  of  it  with  scissors. 

The  cecum  should  never  be  anchored  to  the  skin,  as  in  Gibson's 
operation  (see  Fig.  154),  because  ulceration  ensues  about  the  opening, 
the  feces  escape  to  a  greater  or  less  degree,  and  a  serious  plastic  opera- 


Fig.  160. — Author's  method  of  bury- 
ing the  catheter  in  ordinary  cecostomy  to 
minimize  leakage.  The  tube  can  also  be 
placed  at  a  right  angle  to  the  cecum. 


564      SURGICAL    TREATMENT    OF    THE    GASTRO-INTESTINAL    TR.\CT 

tion  is  later  required  to  free  the  bowel  and  close  the  opening  when  the 
patient  recovers.  On  the  other  hand,  when  the  caput  coli  is  fixed  to 
ihe  inner  abdominal  parietes,  the  fistulous  tract  leading  down  to  it 
can  be  made  to  close  readily  by  cauterizing  its  mucosa  with  silver  or 
a  cautery  point. 

Subsequent  to  appendicostomy  and  cecostomy  leakage  from  the 
catheters  can  be  prevented  by  snapping  a  cravat  clamp  over  their 
ends  or  sides  (Fig.  161),  and  the  annoyance  from  their  slipping  out 
can  be  avoided  by  taking  a  turn  around  them  with  a  narrow  adhesive 
strip  and  attaching  the  two  ends  of  the  plaster  to  the  skin,  then 
repeating  the  process,  and  adjusting  the  strip  so  that  the  ends  are 
fastened  to  the  skin  on  the  other  side  of  the  catheter  (Fig.  162),  and  by 
passing  a  safety-pin  through  the  catherer  and  fastening  it  to  the  skin 
with  plaster  (Fig.  163). 


Fig.  161 . — Method  of  closing  and  retain- 
ing catheters  in  place  with  cravat  clamps 
and  adhesive  strips  following  Gant's  cecos- 
tomv. 


Fig.  162. — INIethod  of  closing  and  re- 
taining catheters  in  place  with  a  ligature 
and  adhesive  strips.     (Gant's  technic). 


Fig.  163. — ilethodof  closing  and  retaining  catheters  in  place  with  safety-pin  and  adhesive 

strips.     (Gant's  technic.) 


Experience  has  demonstrated  to  the  author's  satisfaction  that  in 
the  direct  treatment  of  intestinal  diseases  cecostomy  is  superior  to 
appendicostomy.  and  at  the  June  meeting  (1909)  of  the  American 
Proctologic  Society  he  took  the  position  that,  with  but  few  exceptions, 
it  should  be  given  the  preference.  K  comparative  studj-  of  the 
advantages  of  cecostomy  and  the  disadvantages  of  appendicostomy,  as 
enumerated  below,  will  show  why  the  former  should  take  precedence 
over  the  latter. 

Advantages  of  Cecostomy. — The  advantages  of  this  operation, 
and  more  especially  the  author's  cecostomy,  which  provides  a  means 
of  irrigating  both  the  large  and  small  intestines,  are  as  follows: 

(i)  Owing  to  the  fact  that  the  cecum  lies  against  the  inner  ab- 
dominal parietes  it  can  be  easily  anchored  without  angulating  or 
twisting  the  bowel. 


DISADVANTAGliS    OF    APPKNDICOSTOMY  565 

(2)  Since  the  opening  is  opposite  the  ileocecal  valve  a  catheter 
can  be  introduced  into  the  small  bowel  for  irrigating  purposes  or  the 
siphoning  of  its  contents  for  examination. 

(3)  The  cecal  opening  can  be  made  of  suitable  size. 

(4)  The  circular  valve-like  projection,  formed  around  the  catheter 
by  the  infolding  purse-string  sutures,  prevents  leakage. 

(5)  The  catheter  can  be  changed  without  difficulty. 

(6)  Closure  of  the  opening  follows  withdrawal  of  the  catheter  and 
a  few  applications  of  the  copper  stick  or  cautery. 

(7)  Owing  to  the  natural  position  of  the  cecum  less  tension  and 
pain  foUow-s  its  anchorage  to  the  abdomen  than  the  appendix. 

(8)  Cecostomy  (Gant's)  may  be  employed  in  the  treatment  of 
lesions  located  anywhere  in  the  intestinal  canal,  while  appendicostomy 
is  limited  to  those  of  the  colon. 

(9)  There  is  no  danger  of  an  impaired  circulation  and  sloughing. 

(10)  Therapeutic  bacteria  and  nutriment  can  be  projected  directly 
into  small  intestine  or  colon  following  author's  enterocecostomy. 

Disadvantages  of  Appendicostomy. — (i)  It  is  more  difficult  to  bring 
up  the  appendix  than  the  cecum  for  anchorage  because  of  its  deeper 
and  more  uncertain  position,  and  it  is  frequently  bound  down  l)y 
adhesions  or  a  short  mesentery. 

(2)  Anchoring  of  the  appendix  causes  angulation  or  twisting  ol 
the  cecum,  which,  in  turn,  may  induce  constipation,  discomfort,  or 
pain. 

(3)  When  the  cecum  about  the  appendiceal  base  is  caught  in  the 
wound  it  induces  nausea  and  vomiting  until  detached  (author's  case). 

(4)  When  the  appendix  is  small,  short,  strictured,  bound  down  by 
adhesions,  blocked,  or  otherwise  diseased  it  is  useless  for  irrigating 
purposes. 

(5)  Because  of  the  small  appendiceal  outlet  irrigation  is  frequenth- 
difficult  and  unsatisfactory. 

(6)  Pain  is  much  greater  f(jllowing  appendicostomy  than  cecostomy 
owing  to  the  pulling  upon  the  appendix  by  the  loaded  cecum,  peri- 
appendiceal adhesions,  or  scjueezing  of  the  attached  mesentery-  when 
the  wound  is  closed  tightly  about  it. 

(7)  Frequent  dilation  or  the  insertion  of  a  catheter  is  necessary  to 
keep  the  appendiceal  opening  sufficiently  large. 

(8)  Death  has  followed  injection  of  the  irrigating  fluid  into  the 
abdomen  beside  the  appendix,  where  an  intern  mistook  an  opening 
in  the  wound  for  that  of  the  appendix  (author's  case). 

(9)  After  a  cure  it  is  more  difficult  to  close  the  appendiceal  than  the 
cecal  outlet,  and  appendectomy  may  be  necessary. 

(10)  Appendicostomy  frequently  fails  because  of  the  appendix 
slipping  back  into  the  abdomen  or  retracting  stifficiently  to  make  irri- 
gation almost  or  quite  impossible. 

(11)  The  appendix  has  several  times  been  known  to  slough  off  owing 
to  tension,  its  constriction  by  the  sutures,  or  destruction  of  its  blood- 
supply,  making  cecostomy  imperative. 


566      SURGICAL    TREATMENT    OF    THE    GASTRO-INTESTINAL    TRACT 

(12)  Appendicostomy  is  not  effective  when  the  disease  is  located 
in  the  small  intestine. 

(13)  Appendicitis,  requiring  appendectomy  following  closure  of 
the  appendiceal  outlet,  has  occurred  (author's  case). 

(14)  Owing  to  irritation  caused  by  the  catheter  or  the  treatment 
the  appendiceal  mucosa  may  become  so  inflamed  and  swollen,  ulcer- 
ated, or  strictured  that  irrigation  must  be  abandoned. 

(15)  According  to  Reed,  the  catheter  frequently  causes  the  wall 
of  the  appendix  to  perish. 

(16)  The  appendix  may  be  obstructed  by  a  seed,  fecalith,  or  a  for- 
eign body. 

(17)  A  short  mesentery  may  prevent  bringing  of  the  appendix  to 
the  surface  for  anchorage. 

(18)  Death  has  occurred  from  sloughing  of  the  cecum  about  the 
appendiceal  attachment  on  account  of  tension  (author's  case). 

(19)  Prolonged  traction  upon  the  meso-appendix  has  been  known 
to  cause  frequent  and  enormous  gas  distention  (author's  case). 

(20)  The  appendix  may  be  enormously  sacculated  and  filled  with  a 
mucopurulent  discharge  which  renders  it  unsuitable  for  appendicos- 
tomy. 

(21)  In  a  case  of  the  author's  the  organ  was  larger  than  the  thumb, 
and  cecostomy  was  substituted  for  appendicostomy  because  it  was 
thought  that  the  feces  might  discharge  through  the  appendix. 

(22)  In  two  instances  (author's  cases)  no  appendix  was  found. 
(In  one  the  deformity  was  evidently  congenital,  the  cecum  at  the 
usual  site  of  the  appendiceal  attachment  being  perfectly  smooth;  in 
the  other  an  uneven  appendiceal  stump  was  presented,  appearing 
as  though  the  appendix  might  have  sloughed  at  some  previous  time.) 

(23)  Strangulation  of  the  appendix  at  its  base  may  occur  from 
angulation  or  twisting  when  tension  upon  it  is  great. 

(24)  A  diverticulum  at  the  side  of  the  appendix  (author's  case) 
has  made  appendicostomy  unfeasible. 

(25)  In  fat  subjects,  and  where  the  abdominal  muscles  are  thick, 
the  appendix  is  often  short  and  cannot  be  brought  out  and  sutured  to 
the  skin. 

(26)  The  appendix  may  be  unsuited  because  it  is  congenitally  small 
or  deformed. 

(27)  Sometimes  the  appendix  is  located  extraperitoneally  or  is 
bound  down  by  adhesions,  so  that  it  is  seriously  injured  by  the  dis- 
sections and  is  rendered  unfit  for  irrigating  purposes. 

(28)  Finally,  angulation  and  blocking  of  the  appendix  has  occurred 
(author's  case)  from  the  stab-wound  operation.  In  this  instance  the 
fascia  was  retracted  before  the  stab-wound  was  made,  and  when  the 
wound  was  closed  a  sharp  bend  in  the  appendix  resulted  which  com- 
pletely blocked  subsequent  attempts  at  irrigation. 

Technic  of  Appendicostomy. — Weir,  who  originated  the  operation, 
opened  the  appendix,  passed  a  catheter  through  it  into  the  cecum  to 
see  if  it  was  patent,  ligated  its  tip  to  prevent  leakage,  and  completed 


TECHNIC    OF    APPENDICOSTOMY  567 

the  operation  by  suturing  it  to  the  skin.  Two  days  later  the  hgature 
wa.s  removed  and  the  colon  was  irrigated  tiirough  the  appendix  for 
the  first  time.  Weir  failed  to  anchor  the  appendiceal  base  or  the 
cecum  to  the  abdominal  parietes,  which  left  too  much  tension  upon 
the  appendix  when  the  cecum  was  distended  and  enough  room  about  it 
for  a  hernial  protrusion.  Uawbarn  shortly  thereafter  modified  the 
procedure  by  attaching  the  cecum  about  the  appendiceal  base  to  the 
parietal  peritoneum,  and  Tuttle  (1905)  advised  a  two-stage  operation, 
wherein  the  appendix  was  stitched  in  the  wound  and  later  opened  for 
irrigating  purposes  after  healing  had  taken  place,  claiming  that  in  this 
way  danger  from  infection  could  be  minimized.  Tuttle  also  made  a 
practice  of  ligating  the  appendiceal  artery  and  stripping  the  mesentery 
from  the  appendix  down  to  the  cecum. 

Experience  has  demonstrated  to  the  author's  satisfaction  that 
it  is  not  good  surgery  to  stitch  an  unopened  appendix  in  the  wound, 
since  stricture,  disease,  or  blocking  by  a  foreign  body  may  render 
it  useless  for  irrigating  purposes;  when  infection  complicates  appen- 
dicostomy  the  trouble  is  not  serious  because  it  is  confined  to  the  skin 
sutures. 

Neither  does  the  writer  believe  in  ligating  the  artery  which  parallels 
the  appendix  (see  Fig.  168),  having  known  the  organ  to  slough  off  in 
consequence;  he  makes  a  practice  of  suturing  the  appendix  with  its 
undisturbed  mesentery  into  the  wound  (see  Fig.  167).  The  author 
will  now  give  his  technic  in  appendicostomy. 

Ganfs  Appendicostomy. — Some  surgeons,  through  fear  of  infection, 
prefer  not  to  open  the  appendix  during  the  operation.  Having  en- 
countered three  failures  in  consequence  of  this,  the  author  believes  this 
to  be  a  mistake,  except  when  it  is  obvious  that  the  appendix  is  unob- 
structed. In  one  of  these  cases  the  appendix  was  too  small,  in  an- 
other it  was  strictured,  and  in  the  third  it  was  blocked  by  an  encysted 
grape-seed. 

The  author  amputates  the  appendiceal  tip,  probes  the  appendix, 
and  if  its  channel  is  patent  immediately  introduces  his  probe-pointed 
metal  or  soft  rubber  appendiceal  irrigator  (Fig.  164,  i);  he  then  knows 
nothing  can  interfere  with  postoperative  irrigation.  When  the  appen- 
dix is  diseased,  strictured,  or  blocked  by  a  concretion,  etc.,  it  is  re- 
moved and  cecostomy  substituted  for  appendicostomy. 

It  is  important  that  irrigation  be  started  at  once  in  patients  suffer- 
ing from  ulcerative  colitis  who  are  despondent,  greath-  debilitated, 
having  many  daily  movements,  losing  considerable  l)lood,  or  su tiering 
from  insomnia,  auto-intoxication,  or  mixed  infection. 

To  meet  these  conditions  the  writer  has  devised  a  technic  tor 
appendicostomy  which  pro\ides  for  irrigation  both  during  and  follow- 
ing operation  (Fig.  164).  Since  its  adoption  his  patients  have  gained 
very  much  more  rapidly  than  formerly,  when  the  appendix  was  not 
opened  for  several  days,  during  which  time  nothing  was  done  to  relieve 
them.  Now  and  then  a  stitch-abscess  has  occurred,  l)ut  no  serious 
complications  have  arisen  during  or  following  ()i)erati()n,  and   the  pres- 


568   SURGICAL  TREATMENT  OF  THE  GASTRO-IXTESTIXAL  TRACT 

sure  of  the  irrigator  has  caused  neither  pain,  atrophy,  nor  sloughing 
of  the  appendix. 


Fig.  164. — Steps  showing  Gant's  appendicostomy,  which  pro\-ides  for  immediate  irri- 
gation in  the  direct  treatment  of  bowel  diseases:  1,  Gant's  appendiceal  irrigator;  2.  cecum 
and  appendix  in  position:  A,  A  shows  peritoneum  removed  and  the  gut  being  brought 
in  contact  with  the  transversalis  fascia;  B.  tube  attached  to  irrigator;  C.  C.  suspensorj' 
sutures  which  attach  the  scarified  cecum  to  the  abdominal  wall;  3.  method  of  ligating 
the  appendix  about  the  irrigator  and  closure  of  the  wound;  4  shows  the  irrigator  in  place 
and  the  attached  pieces  of  tape  which  pass  around  the  body  and  retain  it  in  place  when 
fastened,  and  the  rubber  tube  across  which  the  suspensorj-  stitches  (C,  C)  are  tied. 


Briefly  described,  the  steps  in  appendicostomy  as  performed  by  the 
author  are  as  follows: 

First  Step. — The  appendix  is  approached  through  a  gridiron  inci- 
sion, and  located  by  tracing  the  anterior  longitudinal  band  downward, 


TECHXIC    OF    APPEXDICOSTOMY  569 

when  it  and  tlie  cecum  arc  freed,  brought  outside,  and  the  wound  pro- 
tected by  gauze  handkerchiefs. 

Second  5'/e/?.— The  cecum  is  drawn  by  an  assistant  to  first  one  side 
and  then  the  other,  while  the  parietal  peritoneum  is  removed  at  the 
sides  of  the  incision  to  insure  union  between  the  gut  and  the  trans- 
versalis  fascia. 

Third  Step. — The  appendix  is  freed  and  straightened  by  ligating 
and  dividing  adhesions  at  a  safe  distance  from  it,  but  when  the  appen- 
dix is  free  the  mesentery  is  not  disturbed. 

Fourth  Step. — After  the  cecum  has  been  scarified  two  seromuscular 
suspensory  sutures  are  introduced  into  it,  at  the  sides  and  near  the 
base  of  the  appendix,  each  taking  three  bites  in  the  gut  (Fig.  164,  C). 

Fifth  Step. — By  means  of  a  long-handled  needle  the  anchoring 
stitches  are  carried  through  the  abdominal  wall  and  clamped  with 
forceps  for  identification. 

Sixth  Step. — Having  surrounded  the  appendix  with  gauze,  a  trac- 
tion suture  is  introduced  to  stead\'  it  while  its  end  is  being  amputated 
and  cauterized. 

Seventh  Step. — A  Gant  probe-pointed  rubber  or  siKer  appendiceal 
irrigator,  closed  with  a  stopper,  is  introduced,  and  the  appendix  is 
ligated  around  it  above  the  projecting  rim  (Fig.  164,  3). 

Eighth  Step. — The  appendix  is  placed  in  the  lower  angle  of  the 
wound  pointing  upward,  and  anchored  by  two  catgut  sutures  which 
pass  through  the  transversalis  fascia. 

Ninth  Step. — The  abdominal  layers  are  then  approximated  sepa- 
rately, after  which  the  cecal  suspensory  sutures  are  tied  across  rubber 
tubes  (Fig.  164,  4). 

Tenth  Step. — The  irrigator  is  prevented  from  slipping  out  by  the 
adjustment  of  adhesive  straps  or  of  attached  pieces  of  tape  which 
encircle  the  body  (Fig.  164,  4). 

Eleventh  Step. — -In  urgent  cases  from  i  to  3  pints  of  a  warm  saline 
solution  are  immediately  injected  into  the  colon,  when  the  irrigator 
stopper  is  introduced  to  prevent  leakage. 

Twelfth  Step. — The  wound  is  sealed  by  means  of  cotton  and  col- 
lodion, and  further  protected  by  rubber-covered  split-gauze  pads, 
which  overlap  each  other  when  placed  about  the  appendix. 

Thirteenth  Step. — The  end  of  the  irrigator  is  surrounded  by  twisted 
gauze  strips  to  prevent  pressure  upon  it  when  the  outer  dressings  are 
applied. 

The  appendiceal  irrigators  are  made  of  rubber  and  silver,  and  in 
diiTerent  sizes  and  lengths,  to  meet  the  individual  measurements  of  the 
appendix.  In  a  number  of  cases,  after  the  irrigator  had  been  used  to 
dilate  the  appendix  and  facilitate  immediate  drainage  and  irrigation, 
it  was  removed  and  the  flushing  continued  through  the  appendix  or  a 
soft  catheter,  introduced  through  it  into  the  cecum.  In  other  in- 
stances, when  the  instrument  was  not  at  hand,  the  operation  was  per- 
formed as  above  indicated,  except  that  a  piece  of  rubber  tubing  was 
substituted   for  the  irrigator.      Occasionally  too  small  a  channel   is 


570      SURGICAL    TREATMENT    OF    THE    GASTRO-IXTESTINAL    TRACT 

encountered  in  an  tippendix,  but  if  the  organ  is  otherwise  suitable  for 
the  purpose  this  difficulty  can  be  overcome  by  dilatation  with  gradu- 
ated catheters,  probes,  or  slender  forceps,  since  the  appendix  responds 
readily  to  stretching. 

The  appendiceal  stump  should  be  left  projecting  about  j  inch 
beyond  the  skin  (Fig.  164),  so  that  its  opening  can  easily  be  seen; 
otherwise  the  attendant  may  inject  the  irrigant  through  a  mistaken 
opening  beside  it,  as  occurred  in  one  of  the  author's  cases,  where  death 
ensued  as  a  result. 

Appendico-enterocecostomy. — The  author  employs  this  caption  to 
indicate  an  operation  wherein  the  central  part  of  the  appendix  is 
sutured  to  the  skin  for  irrigating  purposes  following  anastomosis  of 
its  distal  end  with  the  lower  ileum  (Fig.  165). 


Fig.  165. — Appendico-enterocecostomy.     (.\uthor's.  technic.) 


Keetley  (1894)^  implanted  the  opened  tip  of  the  appendix  into 
the  lower  ileum,  attached  the  middle  segment  of  the  loop  to  the  skin 
(appendico-enterocecostomy),  and  later  opened  it.  so  that  the  lower 
ileum  and  colon  could  be  irrigated  (Fig.  165).  This  procedure,  how- 
ever, is  in  many  ways  impractical,  and  surgeons  do  not  think  favor- 
ably of  it.  Phillips  (1907)  performed  a  similar  operation,  which  he 
believed  to  be  original. 

The  author  twice  attempted  the  operation  without,  success,  the 
appendix  being  too  short  in  one  instance  and  too  small  in  another. 
On  another  occasion  he  succeeded  in  implanting  the  end  of  the  ap- 
pendix in  the  ileum,  suturing  its  central  part  into  the  skin,  and  later 
^  British  Med.  Jour.,  vol.  ii,  1894. 


STAB-WOUXD    APPEXDICOSTOMV  57  I 

opening  it  (Fig.  165),  l)ut  sloughing  of  the  organ  ensued  at  the  bend, 
retraction  followed,  a  fecal  fistula  formed,  and  the  patient  was  much 
more  miserable  after  than  before  the  operation. 

Stab- wound  Appendicostomy  (Fig.  i66). — In  1907  Pettyjohn  de- 
vised his  stab-wound  operation.  ])erformed  as  follows: 

First  Step. — The  appendix  is  located  through  a  3-inch  incision 
made  over  the  cecum  and  retracted  toward  the  median  line. 

Second  Step. — After  locating  the  appendiceal  attachment  to  the 
cecum  with  the  fingers  a  vertical  stab-wound  is  made  through  the 
abdominal  wall  immediately  over  this  point,  while  the  intestinal  loops 
are  protected  with  a  thick  gauze  pad. 

Third  Step. — A  pair  of  narrow  forceps  is  thrust  through  the  open- 
ing, and  the  appendix  is  drawn  upward  until  the  cecum  is  in  contact 
with  the  abdominal  wall  and  anchored  in  the  wound  by  interrupted 
stitches. 


Fig.  166. — Method  of  attaching  gauze  (A)  and  rolhng  the  appendix  around  it  (B)  to  avoid 
suturing  in  stab-wound  appendicostomy.^ 

Fourth  Step. — The  original  wound  is  closed  with  three  la\-ers  of 
sutures  and  sealed  with  collodion. 

Fifth  Step. — The  appendix  is  then  excised  and  a  catheter  is  inserted 
to  keep  it  patent. 

The  author  does  not  believe  that  this  operation  possesses  any  ad- 
vantages over  other  appendicostomies  in  the  treatment  of  chronic 
diarrhea  incident  to  colitis.  He  has  employed  the  procedure  with 
success  on  several  occasions  in  conjunction  with  resection,  intestinal 
exclusion,  and  colopexy  in  urgent  cases  where  colonic  drainage  was 
indicated,  and  the  patients  were  so  weak  that  the\'  could  endure  neither 
another  large  incision  nor  the  time  reqtiired  for  ordinary  appendicos- 
tomy. 

One  should  know  before  making  the  stab-wound  that  all  the 
abdominal  layers  are  evenly  lined  up,  othervvise  failure  may  result,  as 
occurred  in  a  case  of  the  author's,  where  the  fascia  on  one  side  had  re- 

^  Pettyjohn's  teciinic. 


=,J2      SURGICAL    TREATMENT    OF    THE    GASTRO-IXTESTINAL    TRACT 

traded  and  caused  a  sharp  angulation  in  the  appendix  when  it  was 
sutured  to  that  on  the  other  side  of  the  wound. 

In  performing  appendicostomy  one  should  avoid  kinking  or  twist- 
ing of  the  appendix,  which  interferes  with  subsequent  irrigation;  ten- 
sion upon  it,  which  causes  pain  and  may  lead  to  cecal  sloughing;  inter- 
ference with  the  mesenteric  vessels  by  ligation  (Figs.  167,  i68j  or  com- 
pression in  the  wound,  as  the  appendix  may  thus  become  gangrenous; 
suturing  the  appendix  in  the  wound  before  it  has  been  opened,  since 
it  may  be  blocked  by  a  foreign  body  or  stricture;  catching  the  cecum 
in  the  wound,  which  is  followed  by  persistent  nausea  and  vomiting; 
using  continuous  sutures  for  the  abdominal  layers,  for  if  infection  takes 
place  the  wound  will  open  extensi\el\',  resulting  in  prolonged  con- 
valescence and  a  possible  hernia;  suturing  the  appendix  so  that  it 


^iV 


Fig.  167.— Right  way  of  dealing  -n-ith 
the  me5enter\'  in  appendicostomy  to  pre- 
vent sloughing  following  attachment  of  the 
appendix  to  the  skin. 


Fig.  16S. — Wrong  way  of  deaUng  with 
the  mesentery  in  appendicostomy.  \\'hen 
the  vessels  are  ligated  and  the  mesenter>' 
adjacent  to  the  appendi.x  is  removed, 
sloughing  of  the  appendix  usually  ensues. 


points  downward,  for  leakage  will  ensue;  unnecessary  injury  to  the 
appendix,  its  blood  supply,  or  intestine  to  which  it  may  be  adherent; 
permitting  adhesions  to  remain  which  would  giAe  trouble  subsequently 
by  pulling  upon  the  organ  or  cecum;  leaving  the  cecum  free  to  make 
tension  upon  the  appendix  when  distended  with  gas  or  feces;  large 
catheters,  which  lead  to  atrophy,  ulceration,  or  sloughing  of  the  ap- 
pendiceal mucosa. 

An  appendicostomy  properly  performed  in  suitable  cases  is  devoid 
of  danger,  brings  quick  relief,  induces  scarcely  any  pain,  is  rarely 
followed  by  complications  or  unpleasant  sequelae,  and  is  to  be  recom- 
mended in  all  cases  of  chronic  diarrhea  and  ulcerative  colitis  where 
cecostomy  is  for  any  reason  contra-indicated.  In  the  presence  of 
entamebic  dysentery  the  operation  sliould  not  be  perfonnrd  until  after 


STAB-WOUNU    AFPENUICOSTOMV  573 

the  patient  hiis  been  examined  f<jr  li\er  aljscess,  as  a  sinuillane<jus 
operation  for  this  condition  may  also  be  necessar\-. 

Some  surgeons  scarify  the  appendix,  but  a  firm  union  ma\'  be  had 
wiiiioui  this.  It  should  be  kept  wrapped  in  rubber  tissue  or  gauze 
smeared  with  vasehn  until  amputated  to  prevent  it  sticking  U)  the 
dressing  and  causing  discomfort,  and  be  {protected  from  bandage 
pressure  by  arranging  the  dressing  about  it  in  Ijird's-nest  fashion. 

In  the  author's  experience  no  serious  complications  have  followed 
opening  the  appendix  during  the  operation,  and,  as  by  so  doing  one 
knows  whether  or  not  the  appendix  will  prove  ser\iceable,  he  can  see 
no  advantage  in  the  hvo- stage  operation. 


Fig.  i6g. — Curl's  S-shaped  method  of  anchoring  the  appendix  in  appendicostom3^ 

It  is  advisable  to  pass  the  catheter  well  into  the  cecum,  for  in  one 
of  the  author's  cases  where  a  short  tube  was  used  ulceration  took  place 
below  it,  a  stricture  formed,  and  flushing  was  greatly  interfered  with. 

When  the  appendix  is  bound  down  extensively  by  adhesions, 
clogged,  diseased,  or  otherwise  unfit  for  irrigating  purposes,  it  should 
be  removed  and  an  opening  made  in  the  cecum. 

In  the  presence  of  a  hepatic  abscess  or  gall-stones  the  abdominal 
incision  in  appendicostomy  and  cecostomy  should  be  long  enough  to 
permit  the  operator  to  perform  appendicostomy  or  cecostomy,  as  well 
as  remove  the  stones  or  operate  upon  the  liver. 


CHAPTER   LI  I 

SURGICAL  TREATMENT  OF  DIA"RRHEAL,  INFLAMMATORY, 
OBSTRUCTIVE,  AND  PARASITIC  DISEASES  OF  THE 
GASTRO-INTESTINAL   TRACT   (Concluded) 

TECHNIC  OF  ENTEROSTOMY,  COLOSTOMY,  ENTERECTOMY,  CECEC- 
TOMY,  COLECTOMY,  SIGMOIDECTOMY,   PROCTECTOMY 

Enterostomy. — This  operation  consists  in  anchoring  the  small  in- 
testine to  the  outer  abdominal  wall  or  skin  and  opening  it  to  provide 
immediate  drainage  in  acute  obstruction,  or  to  form  an  artificial  anus 
in  cases  of  inoperable  chronic  obstruction  of  the  cecum  or  small  bowel. 

The  small  intestine  is  rarely  fixed  and  opened,  and  when  it  is,  it  is 
usually  done  for  the  relief  of  paralytic  ileus  or  an  enormously  distended 
bowel  filled  with  gas,  feces,  and  virulent  bacteria. 

Enterostomy  leaves  the  patient  in  a  deplorable  condition  because 
of  the  almost  incessant  discharge  of  fluid  feces,  which  is  disgusting  to 
the  patient,  keeps  the  skin  about  the  wound  in  a  constant  state  of 
irritation,  and  leads  to  malnutrition  because  the  chyme  is  discharged 
before  its  nutrient  elements  have  been  absorbed. 

The  colon,  on  the  contrary,  is  quite  frequently  opened,  either  to 
give  vent  to  the  contents  of  an  acutely  obstructed  bowel  for  the  pur- 
pose of  forming  a  permanent  artificial  anus,  or  as  a  preliminary  step  to 
excision  of  the  rectum. 

Simple  enterostomy  is  a  makeshift  to  carry  the  patient  over  a 
dangerous  period  in  his  illness,  and  the  opening  is  not  supposed  to  be 
lasting,  but  when  an  artificial  anus  is  established  it  is  usually  a  per- 
manent affair;  consequently,  the  technic  of  these  procedures  must 
necessarily  differ. 

In  enterostomy  no  attempt  is  made  to  give  the  patient  control 
over  the  evacuations,  the  object  being  to  relieve  distention  and  pro- 
vide a  means  of  irrigation,  so  that  the  intestine  may  be  immediately 
cleansed  of  contained  poisons.  On  the  other  hand,  when  a  permanent 
anus  is  formed,  pains  are  taken  to  make  it  effective,  so  that  the  patient 
will  not  be  annoyed  by  involuntary  movements  or  protrusion  of  ihe 
gut  through  the  opening. 

Simple  enterostomy,  or  a  fecal  fistula,  can  be  quickly  and  effectively 
made  by  freeing  and  drawing  the  segment  of  bowel  situated  above 
the  point  of  obstruction  up  into  the  wound  and  stitching  it  to  the  fascia 
or  muscular  layers.  The  stitches  should  be  made  to  dip  into  the  mus- 
culature of  the  intestine  in  order  to  give  a  firm  support.  When  the 
colon  is  opened  additional  sutures  should  be  introduced  at  the  angles 
of  the  incision  which  will  pass  beneath  the  longitudinal  band.     When 

574 


COLOSTOMY  575 

the  manifestations  arising  from  distention  are  not  dangerous  the  gut 
should  not  be  opened  for  a  day  or  t%vo,  but  when  the  condition  of  the 
patient  is  critical  it  should  be  punctured  within  a  few  hours,  by  which 
time  the  peritoneal  cavity  will  have  become  walled  off. 

When  it  is  imperative  that  the  bowel  should  be  opened  immedi- 
ately to  save  life,  a  loop  of  the  intestine  should  be  brought  outside  the 
wound,  opened,  and  ligated  around  a  Paul  glass  tube  by  means  of  a 
seromuscular  purse-string  suture,  or  the  gut  may  be  divided  between 
clamps,  and  a  tube  placed  in  either  end  and  made  to  connect  with  a 
basin  under  the  bed  by  means  of  rubber  piping.  Experience  has 
shown  that  fecal  fistuUc  heal  more  frequently  and  quickly  when  the 
intestine  is  fixed  to  the  deeper  abdominal  layers  than  when  it  is  stitched 
to  the  skin. 

Colostomy.— Now  and  then  it  becomes  necessan,-  to  colostomize 
patic-nts  suffering  from  chronic  mechanic  diarrhea  induced  by  a  growth, 
stricture,  angulation,  adhesion,  volvulus,  invagination,  foreign  body, 
diverticulum,  or  enteroptosis,  etc.,  after  other  measures  have  been 
tried  and  proved  inefficient. 

An  artificial  anus  should  never  be  made  to  relieve  this  class  of 
sufferers  except  as  a  last  resort,  because  patients  seriously  object  to 
having  the  opening  in  the  side,  they  do  not  have  perfect  control  over 
the  evacuations,  and,  further,  because  a  second  and  more  dangerous 
operation  is  necessary  should  they  ever  desire  to  have  the  artificial 
anus  closed.  When  an  inoperable  stricture,  growth,  angulation,  etc., 
causes  obstipation,  and  a  new  route  must  be  found  for  the  feces,  the 
author  prefers  entero-anastomosis  and  exclusion  of  the  involved  seg- 
ment of  gut  to  colostomy,  because  it  relieves  the  diarrheal  state,  is  not 
accompanied  by  the  objectionable  features  of  an  artificial  anus,  and 
does  not  require  a  possible  secondary  operation.  An  artificial  anus 
may  be  temporary  when  made  as  a  preliminar\-  step  to  excision  and 
resection,  or  until  such  time  as  the  condition  for  the  relief  of  which  it 
was  made  has  been  cured;  or  permanent  when  the  opening  is  to  remain 
through  life. 

In  temporary  colostomy  the  object  sought  is  to  keep  the  feces  away 
from  the  field  of  operation  for  a  few  days  before  and  following  the 
operation  and  then  to  close  the  opening;  consequently,  it  is  not  neces- 
sary' to  spend  as  much  time  in  the  formation  of  a  temporary  anus  as  it 
is  in  the  making  of  one  which  is  to  be  permanent. 

In  permanent  colostomy  it  is  of  the  utmost  importance  for  the 
patient's  comfort  to  make  the  opening  of  a  suitable  size,  and  to  do  the 
operation  in  such  a  way  that  he  may  not  be  bothered  with  painful 
evacuations,  fecal  incontinence,  or  procidentia. 

Practically  all  surgeons  now  locate  the  anus  in  the  left  inguinal 
region,  except  when  the  pathologic  lesion  necessitating  the  operation  is 
situated  further  up,  when  the  outlet  is  made  in  the  transverse  colon  or 
right  inguinal  region,  according  to  the  indications. 

Except  where  there  are  special  reasons  for  doing  othervvise,  the 
aperture  should  be  made  as  low  down  as  possible,  because  here  the 


576      SURGICAL    TREATMENT    OF    THE    GASTRO-INTESTINAL    TRACT 

feces  are  more  solid  and  give  less  trouble  than  when  the  anus  is  estab- 
lished at  or  near  the  cecum. 

In  recent  years  Bailey,  Weir,  Witzel,  Tuttle,  the  author,  and  others 
have  devised  special  technics  designed  to  overcome  the  disgusting 
features  of  the  old-fashioned  artificial  anus  and  give  the  patient  control 
over  the  opening,  and  each  operator  has  met  with  more  or  less  success. 

The  technic  of  the  abo\'e-named  operators  has  been  given  else- 
where by  the  author,'  and  here  he  need  not  do  more  than  briefly  de- 
scribe his  own  operation,  which  has  proved  eminently  satisfactory  in 
more  than  lOO  cases. 

The  Author's  Colostomy. — The  sigmoid  is  approached  through  a 
2-inch  incision,  which  crosses  a  line  extending  between  the  umbilicus 


Fig.  170. — Relation  of  the  gut  to  the  muscles,  fasciae,  fat,  and  skin  in  Gant's  colostomy. 

and  the  anterior  spine  of  the  ileum,  at  the  inner  border  of  the  oblique 
muscles;  working  outward,  the  transversalis  is  separated  from  the 
internal  oblique,  with  the  index-  and  middle  fingers,  for  about  i  to  i^ 
inches  (2.5-3.8  cm.).  The  fingers  are  then  forced  upward  through 
the  two  oblique  muscles,  and  finally  over  the  external  oblique  and 
inward  to  the  incision,  thereby  separating  the  subcutaneous  fat  from 
the  muscle.  A  loop  of  the  sigmoid  is  now  hooked  up  and  then  made  to 
travel  the  route  taken  by  the  fingers,  which  makes  it  pass  outward 
between  the  internal  oblique  and  the  transversalis  muscles,  and  then 
through  and  over  the  external  oblique  to  the  incision,  where  it  is 
1  Diseases  of  the  Rectum  and  Anus,  3d  ed. 


THE    AUTHOR  S    COLOSTOMY  577 

sutured  after  being  made  taut  to  avoid  a  subsequent  procidentia. 
The  angles  of  the  wound  are  approximated  by  two  chromicized  catgut 
sutures,  which  pass  through  the  skin  and  fascia  on  one  side  of  the 
incision  and  then  beneath  the  longitudinal  band  of  the  sigmoid  and 
out  through  the  same  structures  on  the  other  side,  where  they  are  tied 
(Figs.  1 70,  171).  After  the  gut  has  been  attached  to  the  skin  by  a  few 
plain  catgut  stitches  (Pig.  171),  it  is  covered  with  rubber  tissue,  lubri- 
cated with  sterile  vaselin  to  prevent  sticking,  and  then  the  outer 
dressing  and   binder  are  applied.     Patients  ha\"e   but  little  control 


Fig.  lyi.^Side  \-ie\v  of  the  gut  after  it  has  been  brought  out  of  the  abdomen,  and  method 
of  applying  the  angular  and  fixation  sutures  in  Gant"s  colostomy. 

over  an  artificial  anus  for  the  first  few  days,  no  matter  what  operation 
is  performed,  because  the  soreness  of  the  wound  and  the  irritability 
of  the  intestine  excite  frequent  and  strong  peristalsis  accompanied  by 
the  involuntary  discharge  of  feces. 

Except  during  attacks  of  diarrhea  the  author  has  rarely  known  a 
patient  to  have  more  than  one  or  two  actions  daily  following  his 
operation.  In  fact,  he  has  treated  many  of  his  colostomized  patients 
for  constipation. 

A  study  of  the  position  of  the  gut,  as  shown  in  the  accompanying 

37 


578   SURGICAL  TREATMENT  OF  THE  GASTRO-INTESTINAL  TRACT 

illustrations  (Figs.  170,  171).  will  make  it  easy  for  the  reader  to  under- 
stand why  the  operation  is  not  followed  by  incontinence. 

This  procedure  has  the  advantage  over  the  Bailey,  Weir,  Witzel, 
and  Tuttle  technics  in  that  but  one  incision  is  made  instead  of  two,  and, 
further,  because  it  gives  the  patient  a  more  perfect  control  over  the 
movements  than  do  the  others.  The  author's  patients  rarely  complain 
of  the  involuntary  escape  of  gas,  and  usually  do  not  have  an  evacuation 
until  they  desire,  when  they  stimulate  peristalsis  by  the  injection  of 
2  or  3  ounces  (60.0  or  90.0)  of  warm  water  into  the  upper  opening. 

The  bowel  is  not  opened  until  the  third  day  except  when  there  is 
a  marked  distention  and  suffering;  under  such  circumstances  it  is 
punctured  at  any  time  after  six  hours  and  amputated  later.  The 
projecting  piece  of  gut  can  be  quickly  and  painlessly  removed  under 
local  anesthesia  induced  by  the  injection  of  a  small  quantity  of  a 
I  per  cent,  eucain  solution  into  its  mesentery.  Cutting  of  the  bow^el 
proper  causes  no  pain  and  does  not  require  anesthetizing. 

The  bowel  is  amputated  by  a  few  bold  cuts  of  the  scissors  about 
J  inch  from  the  skin,  to  allow  for  retraction.  Bleeding  points  are 
ligated  en  masse,  and  hemorrhage  from  oozing  surfaces  is  controlled 
by  hot-water  compresses,  adrenalin,  or  a  solution  of  iron  or  the  cautery. 
The  raw  edges  left  can  be  encouraged  to  heal  rapidly  by  the  occasional 
application  of  silver  nitrate  (6  per  cent.).  When  the  obstruction  is 
located  above  the  sigmoid  the  steps  in  the  operation  must  necessarily 
be  modified  to  meet  the  indications,  but  desirable  changes  in  the  tech- 
nic  will  at  once  suggest  themselves  to  the  experienced  surgeon. 

ENTERECTOMY,     COLECTOMY,     CECECTOMY     (TYPHLECTOMY),     SIG- 
MOIDECTOMY,  AND  PROCTECTOMY 

Enterectomy,  the  removal  of  a  fraction  of  the  intestine,  is  justi- 
fiable in  acute  and  chronic  obstruction  where  life  is  endangered  and 
relief  cannot  be  given  in  any  other  way.  In  the  context  the  term 
enterectomy  will  be  limited  to  partial  resections  of  the  small  intestine, 
whereas  the  corresponding  operations  upon  the  large  bowel,  according 
to  their  topography,  will  be  discussed  under  the  headings  of  Cecectomy 
or  Typhlectomy,  Colectomy,  Sigmoidectomy,  and  Proctectomy. 

Resection  of  the  small  intestine  is  rarely  performed  for  the  relief 
of  chronic  diarrhea  because  lesions  responsible  for  the  condition  are 
usually  located  in  the  colon,  sigmoid  flexure,  or  rectum.  In  the  treat- 
ment of  this  form  of  diarrhea  it  quite  frequently  becomes  necessary  to 
remove  a  small  or  considerable  portion  of  the  large  bowel  or  rectum 
to  free  it  from  a  tumor,  stricture,  foreign  body,  angulation,  twist, 
diverticulum,  adhesion,  stricture,  or  other  obstructing  lesions  which 
block  passage  of  the  feces. 

Operators  are  often  inclined  to  be  conservative  as  regards  the 
amount  of  bowel  they  remove,  but  this  is  frequently  a  mistake.  It  is 
far  safer  to  take  away  a  liberal  amount  of  healthy  gut  than  it  is  to 
leave  even  a  small  portion  of  diseased  intestine,  which  might  lead  to 


ENTERPXTOMY 


579 


cutting  out  of  the  stitches  and  peritonitis,  the  formation  of  a  fecal 
fistula,  or  a  recurrence  of  the  trouble. 

A  few  years  ago  when  making  an  artificial  anus  the  auth<jr  brought 
outside  the  abdomen  only  a  sufficient  amount  of  gut  to  form  a  relial)le 
spur  and  provide  a  useful  opening,  but,  as  a  result,  many  of  his  colosto- 
mized  patients  suffered  from  protrusion  of  the  rectum  or  descending 
colon  through  the  artificial  opening.  In  his  last  200  colostomies  he 
has  excised  from  3  to  15  inches  of  the  gut  to  obviate  this  complication, 
and  no  ill  consecjuences  have  followed. 

Experiments  upon  animals  and  Lane's  colonic  excisions  and  opera- 
tions upon  the  large  gut  have  demonstrated  that  one-third  of  the  small 
intestine  can  be  resected  and  a  large  part  or  all  of  the  colon  be  excised 
without  appreciable  harm,  but  when  as  much  as  one-half  or  more  of 
the  small  bowel  is  removed  digestive  disturbances  arise  and  death 
ensues  from  inanition.  Surgeons  have  on  many  occasions  removed 
from  5  to  12  feet  of  the  small  or  large  bowel,  and  their  patients  have 
recovered  and  lived  in  comfort  afterward.  The  following  table  of 
cases,  collected  by  Park,^  gives  many  examples  where  several  feet  of 
intestine  have  been  resected: 


CASES  OF  INTESTINAL   RESECTION  WITH  REMOVAL  OF  MORE  THAN  6  FEET  8  INCHES 
(200  CENTIMETERS)   OF  INTESTINE. 


Operator. 


1.  Koeberle 6  ft.  lo    in. 

2.  Kocher 6  ft.  ii     in. 

3.  Dressman 7  ft.     2    in. 

4.  Shepherd 7  ft.    9    in. 

5.  Kukula 7  ft.    9    in. 

6.  Harris 7  ft.  10    in. 

7.  Hayes 8  ft.    45  in. 

8.  Peck 8  ft.    si  in. 

9.  Lawers 8  ft.    9    in. 

10.  Roswell  Park 8  ft.    9    in. 

11.  Payr 9  ft.       \  in. 

12.  Maydl 9  ft.    4    in. 

13.  Fantino 10  ft.    4    in. 

14.  Monprofit !  10  ft.    4    in. 

15.  Ruggi. i  II  ft. 

16.  Von  Eiselsberg |  11  ft.    8    in. 

17.  Obalinski 12  ft.     2    in. 


Amount  removed. 


(205  cm.). 
(208  cm.). 
(215  cm.). 
(234  cm.). 
(237  cm.). 
(239  cm.). 
(248  cm.). 
(251  .m.). 
(265  cm.). 
(265  cm.). 
(275  cm.). 
(2S4  cm.). 
(310  cm.). 
(310  cm.). 
(330  cm.). 
(350  cm.). 
(365  cm.). 


Result. 


Recovered. 

Recovered. 

Recovered. 

Recovered. 

Recovered. 

Recovered. 

Recovered. 

Recovered. 

Recovered. 

Recovered. 

Recovered. 

Died  three  weeks  later  of  inanition. 

Recovered. 

Recovered. 

Recovered. 

Death  after  twenty-live  days. 

Died. 


In  so  far  as  the  colon  is  concerned,  the  author's  experience  warrants 
the  statement  that  it  makes  very  little  difference  whether  a  short  or 
long  .segment  or  all  the  colon  is  remoAcd,  because  the  ileum,  to  a  great 
extent,  takes  upon  itself  the  functions  of  the  colon  when  the  latter 
has  been  resected  or  excluded  by  entero-anastomosis.  His  experience 
agrees  with  that  of  Lane,  in  that  the  stools  following  colonic  resection 
are  at  first  frequent  and  fluid,  bu*^  gradually  the  actions  become  less 
frequent,  and,  finally,  normal  '.a  number  and  consistence.  Imder 
^  Buffalo  MA.  Jour.,  April,  1903. 


580      SURGICAL    TREATMENT    OF    THE    GASTRO-IXTESTINAL    TRACT 

such  circumstances  the  lower  ileum,  upon  examination,  was  found  in 
2  of  the  author's  cases  to  be  enlarged  and  acted  as  a  reservoir  in 
which  the  feces  remained  until  the  watery  constituents  had  been  ab- 
sorbed and  the  stools  became  formed  and  ready  for  expulsion. 

Enterectomy  (especially  colectomy)  is  indicated  more  frequently 
in  men  than  in  women,  and  has  been  performed  more  than  twice  as 
frequently  in  persons  between  the  ages  of  thirty  and  sixty  than  in 
older  or  younger  individuals. 

On  account  of  their  great  mobility,  the  small  intestine,  transverse 
colon,  and  sigmoid  flexure  arc  more  easily  resected  than  the  cecum  or 
hepatic  and  splenic  flexures,  which  are  tied  down  by  their  mesenteric 
ligamentous  attachments  or  contracting  adhesions,  which  makes  their 
removal  extremely  arduous.  It  is  invariably  easier  to  resect  a  piece 
of  the  small  bowel  than  a  similar  segment  of  the  colon,  because  the 
latter  is  larger,  thicker,  and  more  generously  surrounded  with  fat,  and 
is  often  bound  down  by  adhesions  or  a  short  mesocolon. 

Except  that  a  little  more  care  is  necessary  in  placing  the  mesenteric 
sutures  following  colonic  resection,  the  technic  of  operations  upon  the 
small  and  large  intestine  is  about  the  same. 

The  mortality  following  colectomy  for  the  relief  of  cancer  is  greater 
than  for  other  types  of  mechanical  obstruction  causing  obstipation, 
and  the  results  are  not  so  good. 

Patients  upon  whom  a  cecectomy,  colectomy,  or  sigmoidectomy  is 
about  to  be  performed  should  be  prepared  for  the  operation  by  freeing 
the  bowel  of  accumulated  feces  (when  possible),  washing  out  the 
stomach,  and  disinfecting  the  skin  with  iodin,  etc. 

General  anesthesia  is  preferable  for  resection  operations  in  chronic 
obstruction  from  all  causes  when  the  condition  of  the  sufferer  is  good, 
but  if  the  bowel  is  completely  blocked  and  vitality  is  lowered  because 
of  enormous  distention  and  absorption  of  virulent  poisons  it  is  fre- 
quently advisable  to  open  the  abdomen  and  incise  and  drain  the  bowel 
under  local  or  infiltration  anesthesia  (|  per  cent,  eucain  solution). 
When  the  type  and  location  of  the  obstruction  are  known  in  advance 
it  may  be  reached,  and  the  intestine  resected  through  an  intermus- 
cular incision  made  directly  over  the  lesion,  but  when  there  remains 
a  doubt  as  to  which  part  of  the  colon  is  blocked,  a  liberal  median  or 
Kammerer  incision  is  preferable. 

A  collapsed  large  bowel  points  to  small  intestinal  obstruction,  and 
a  highly  distended  colon  to  a  block  in  its  lowermost  segments  or  the 
rectumi. 

When  the  patient  is  extremely  ill  or  in  a  state  of  collapse  from 
acute  obstruction,  resection  and  anastomosis  are  extremely  dangerous, 
and  the  patient  stands  a  better  chance  from  the  operation  and  of  ulti- 
mately obtaining  a  permanent  cure  when  an  immediate  vent  is  pro- 
vided for  the  retained  feces,  gas,  and  toxins,  and  the  radical  operation 
is  postponed  until  later  when  the  patient's  powers  of  resistance  are 
greater. 

In  case  opening  of  the  bowel  is  contemplated,  it  should  be  brought 


ENTERECTOMY  58 1 

outside  and  walled  off  with  gauze  after  it  has  been  freed  from  exudates 
or  firm  adhesions  by  a  gauze  w^ipe  or  scissors.  The  distended  bowel 
can  then  be  quickly  drained  by  means  of  appendicostomy,  valvular 
cecostomy,  colostomy,  or  by  simply  stitching  a  part  of  the  colon  (to 
be  opened  later)  above  the  obstruction  to  the  skin  without  any  attempt 
at  making  a  spur  (simple  colostomy).  Another  popular  way  of  obtain- 
ing quick  drainage  is  to  divide  the  bowel  and  ligate  each  }>iece  of  the 
intestine  to  one  end  of  a  PauU  glass-tube,  to  the  other  of  which  is 
attached  a  rubber  pipe  that  carries  the  bowel  contents  into  a  vessel 
beneath  the  bed.  When,  for  any  reason,  the  surgeon  does  not  wish  to 
sever  the  bowel,  it  can  be  opened  inside  a  purse-string  suture,  which 
is  then  tied  around  a  colon-tube.  Some  surgeons  advocate  immediate 
incision  and  irrigation  of  the  gut,  while  others  prefer  to  empty  the 
bowel  by  stripping  it  over  a  long  glass  tube  similar  to  the  one  designed 
by  Moynihan. 

Resection  of  the  obstructed  segment  ma\-  be  done  shortly  follow- 
ing drainage  if  conditions  are  favorable,  or  the  operation  may  be 
deferred  for  Aveeks  or  months,  when  the  opening  serv^es  to  keep  the 
patient  comfortable  and  the  bowel  free  from  fecal  accumulations. 

As  a  general  rule,  obstruction  produced  by  chronic  lesions  is  not 
complete  and  a  drain  is  not  imperative.  Naturally,  cecectomy, 
colectomy,  and  sigmoidectom\'  are  more  dangerous  when  performed  for 
the  relief  of  acute  than  chronic  obstruction  because  of  the  distressing 
manifestations  present  at  the  time  of  operation.  In  fact,  these  opera- 
tions, when  done  for  the  relief  of  chronic  mechanic  obstruction,  are 
not  nearly  as  dangerous  or  difficult  to  perform  as  surgeons  of  slight 
experience  imagine. 

Following  cecectomy  and  colectomy  it  is  often  necessary  to  cover 
raw  surfaces  of  the  abdominal  parietes  and  bow'el  with  peritoneum 
to  avoid  the  formation  of  adhesions  or  hernia. 

The  author  has  resected  the  cecum  alone,  or  including  a  part  of 
the  colon,  twice  for  cecal  cancer,  once  for  chronic  irreducible  ileocecal 
invagination,  twice  for  otherwise  inoperable  adhesions,  once  for  acute 
olistruction  and  perforation  caused  by  thread-like  fibrous  bands,  and 
once  for  chronic  volvulus  (ascending  colon)  caused  by  contracting 
adhesions  which  pulled  its  upper  extremity  in  one  direction  and  the 
lower  in  another,  with  but  2  deaths.  In  most  of  these  cases,  after  a 
blind  end  had  been  formed  in  the  colon,  the  ileum  was  severed,  the 
divided  ends  closed,  and  an  anastomosis  made  between  it  and  the 
sigmoid  or  rectum.  Considering  the  nature  of  the  lesions  and  the 
condition  of  patients  at  the  time  of  operation  the  results  obtained  from 
resection  in  these  cases  were  very  satisfactory.  Except  when  adhesions 
are  very  numerous  and  firm,  or  the  bowel  is  greatly  distorted,  removal 
of  the  cecum  is  not  a  very  difficult  procedure. 

Cecectomy  (typhlectomy),  colectomy,  and  sigmoidectomy  are  ex- 
tremely difficult  where  the  patient  is  fat,  because  of  the  thickness  of 
the  abdomen  and  the  large  amount  of  fat  in  the  mesentery  and  around 
'  Brit.  .Med.  Jour.,  May  25,  1895,  p.  1139. 


582       SURGICAL    TREATMENT    OF    THE    GASTRO-INTESTIXAL    TRACT 

the  bowel.  Naturally,  the  most  movable  portions  of  the  colon  are  more 
easy  to  resect  than  those  which  are  fixed  by  the  mesocolon. 

Bleeding  should  be  completely  arrested  before  the  abdomen  is 
closed  by  suturing  the  raw  or  torn  surface,  or  applying  the  cauter\% 
adrenalin,  iron,  or  hot  water  to  it  until  hemorrhage  has  been  controlled. 

Postoperative  adhesions  may  be  forestalled  by  a\"oiding  bruising 
the  viscera  and  peritoneum,  clearing  the  abdomen  of  blood,  covering 
denuded  surfaces  with  the  serosa,  aristol,  tallow,  or  Cargile's  mem- 
brane, or  frequently  changing  the  position  of  the  patient,  and  pre- 
scribing eserin  to  excite  peristalsis  and  prevent  inflamed  or  raw  sur- 
faces of  the  intestinal  loops  from  constantly  remaining  in  contact. 

Proctectomy. — This  procedure  is  called  for  in  the  treatment  of  in- 
flammatory- and  ulcerative  lesions,  strictures,  diverticula,  benign  and 


Fig.  172. — Method  of  amputating  the  rcLium  aficr  it  has  been  freed  frum  its  attachments 

in  superior  proctectomj". 


non-malignant  tumors,  distortions  of  the  rectum,  and  other  diseases 
of  the  rectum  causing  obstruction  or  diarrhea  which  cannot  be  elimi- 
nated by  less  radical  measures. 

The  author  has  in  many  instances  cured  chronic  diarrhea,  relieved 
pain,  arrested  offensive  discharges,  improved  digestion,  overcome 
anemia  and  cachexia,  and  caused  patients  to  rapidly  regain  their 
normal  health  and  weight  by  removing  all  or  a  part  of  the  lower  bowel 
which  was  blocked,  extensively  ulcerated,  or  intensely  inflamed  and 
irritable. 

Amputation  or  resection  of  the  rectum  is  preferable  to  colostomy 
in  aggravated  cases  because  by  it  the  diseased  bowel  is  immediately 
gotten  rid  of  and  the  patient  does  not  have  a  disgusting  artificial  anus 


PROCTECTOMY  583 

to  look  after.  The  rectum,  according  to  indications,  may  be  removed 
by  the  following  methods,  \iz.: 

(a)  Inferior  proctectomy  (perineal  excision) ;  (b)  superior  proctec- 
tomy (sacral  excision) ;  (c)  vaginal  proctectomy,  and  (d)  celio proctectomy 
(alxlominoi)erineal  proctectomy) . 

Inferior  Proctectomy. — Practically  all  rectal  cancers  located  in  the 
lower  3  inches  (7.62  cm.)  of  the  rectum  can  be  speedily  and  safely 
removed  by  this  procedure,  which  consists  in  beginning  below  and  free- 
ing the  rectum  upward  sufficiently  high  to  permit  the  operator  to  excise 
the  gut  at  a  safe  distance  above  the  growth. 

In  favorable  cases  extensive  tumors  and  several  inches  of  the  bowel 
can  be  easily  removed  by  perineal  excision  with  little  danger  to  the 
patient. 


f 


Fig.  173. — Appearance  of  wound  and  location  of  the  sacral  opening  after  superior  proctec- 
tomy where  the  gut  cannot  be  brought  down  to  the  normal  site  of  the  anus. 

Superior  Proctectomy  (Sacral  Excision). — Aggravated  cases  of 
cancer  located  in  the  upper  third  of  the  rectum  or  at  the  rectosigmoid 
juncture  cannot  always  be  extirpated  by  inferior  or  vaginal  proctec- 
tomy, and  excision  of  the  coccy.x  or  lower  sacrum  (Kraske)  is  neces- 
sary to  give  the  surgeon  sufficient  room  in  which  to  isolate  and  remove 
the  growth  (Figs.  172,  173). 

Coccygeal  excision  is  all  that  is  recjuired  in  most  instances,  but 
removal  of  the  sacrum  l:)elow  the  third  \'ertebral  opening  is  ad\-an- 
tageous  and  greatly  facilitates  the  extirpation  of  high  cancers  without 
greatly  endangering  the  patient's  life.  The  formation  of  a  sacral 
anus  is  often  imperative  in  this  operation,  but  the  removal  of  bone 
weakens  pelvic  support,  and  for  these  reasons  inferior  and  vaginal 
proctectomies  are  preferable  to  Kraske's  procechire  in  feasil)le  cases. 


584      SURGICAL    TREATMENT    OF    THE    GASTRO-INTESTIXAL    TRACT 

Vaginal  Proctectomy. — The  author  invariably  removes  cancers  of 
the  lower,  middle,  and  upper  rectum  in  women  by  the  vaginal  route 
(Figs.  174,  175),  because  splitting  of  the  vaginal  septum  and  perineum 
gives  an  abundance  of  room  in  which  to  work,  frequently  avoids  de- 
struction of  the  sphincter  muscle,  and  removal  of  the  bony  pelvic  sup- 
port greatly  facilitates  the  operation.  On  several  occasions  he  has 
succeeded  in  removing  several  inches  of  the  sigmoid  flexure  with  the 
upper  rectum  by  the  vaginal  route.  When  the  peritoneal  cavity  has 
been  opened  to  free  the  bowel,  it  can  be  easily  and  quickly  closed 
and  drained.  In  this  procedure  it  is  easy  to  unite  the  lower  and 
upper  rectal  segments  following  extirpation  of  the  tumor,  or  where 


Fig.  174. — Proctectomy  by  the  vaginal  route,  showing  Gersuny's  tv\-ist.    (Author's  technic.) 

the  distal  end  is  diseased  and  must  be  removed,  the  proximal  end  of 
the  bowel  can  easily  be  drawn  down  and  sutured  to  the  perianal  skin. 

Celioprocteciomy  {Abdominoperineal  Excision). — When  a  growth 
involves  the  upper  rectum,  or  it  and  the  lower  sigmoid  flexure  cannot 
be  extirpated  by  inferior,  superior,  or  vaginal  proctectomy  alone,  one  is 
justified  in  resorting  to  the  combined  operation. 

In  this  procedure  the  abdomen  is  opened,  the  diseased  gut  is  iso- 
lated, ligated,  and  divided,  after  which  the  proximal  end  is  stitched  in 
the  wound  (colostomy)  and  the  distal  end,  following  severance  of  its  peri- 
toneal reflexion,  is  pushed  downward  and  the  serosa  is  closed  above  it. 
The  abdominal  wound  is  then  closed  and  the  diseased  gut  is  extirpated 


INTESTINAL    EXCLUSION 


58  = 


b>'  inferior,  superior,  or  vaginal  proctectomy.  Patients  object  to  an  ar- 
tificial anus  in  the  side,  consequently,  when  feasible,  the  sigmoid  should 
be  mobilized  by  sewing  its  mesenteric  attachments,  dividing  the  in- 
ferior mesenteric  or  superior  hemorrhoidal  artery,  and  incising  the 
peritoneum  about  the  gut,  which  enables  the  operator  to  easily  free  the 
upper  rectum,  push  the  sigmoid  downward,  and  close  the  peritoneal 
cavity.  He  can  then  quickly  excise  the  necessary  amount  of  bowel  by 
either  perineal,  sacral,  or  vaginal  excision. 

Preservation  of  the  sphincter  nnisde  is  desir- 
able, but  unless  considerable  care  is  used  all 
cancerous  tissue  is  not  removed,  in  which  case 
local  recurrence  will  shortly  follow.  When 
the  anal  segment  and  sphincter  are  healthy  the 
mobilized  proximal  end  of  the  bowel  may  be 
anastomosed  with  it  in  situ,  pulled  down,  and 
sutured  to  the  skin  after  the  mucosa  has  been 
removed  from  the  anal  canal,  or  the  lower  can 
be  invaginated  and  the  upper  end  of  the  rec- 
tum be  drawn  through  and  sutured  to  it, 
following  which  the  intact  bowel  is  replaced. 
Many  patients  have  control  over  solid  fecal 
matter  following  the  establishment  of  a  sacral 
anus,  and  not  a  few  can  retain  fluid  feces  when 
the  gut  is  twisted  vipon  itself  before  being  su- 
tured to  the  skin. 

Bleeding  is  controlled  by  packing  one  side 
of  the  gut  with  gauze  compresses  wrung  out  of 
boiling  water  while  the  other  is  being  freed. 
When  the  gut  has  been  completely  isolated  and 
the  growth  removed  between  double  ligatures 
placed  on  either  end,  ligation  of  the  rectum 
about  a  large  rubber  tube  prevents  bleeding 
when  it  is  amputated.  Sometimes  the  author 
sutures  the  bowel  to  the  skin,  cuts  it  off,  and 
controls  hemorrhage  b>^  t\ing  the  vessels  sepa- 
rately as  severed. 

For  a  detailed  description  of  inferior,  supe- 
rior, and  vaginal  proctectomy  and  celioproctectomy  the  reader  is  referred 
to   the    author's  work.    Intestinal   Stasis    ("Constipation  and    Obsti- 
pation"). 

Intestinal  Exclusion. — This  procedure  consists  in  shutting  off  the 
fecal  currenl  from  an  intestinal  segment  to  relieve  obstruction  or  give 
rest  to  the  mucosa  when  involved  by  inflammatory  or  ulcerative  lesions 
that  cause  obstipation  or  loose  movements  alternating  ivith  costiveness  or 
diarrhea.  All  or  a  part  of  the  small  or  large  intestine  may  be  excluded 
by  entero-anastomosis  (Fig.  176),  closing  the  bowel  on  one  side  of  the  dis- 
eased gut.  and  uniting  the  proximal  extremity  to  the  intestine  below — 
unilateral  exclusion  (Fig.  18);  or  by  boxing  in  the  lesion  on  both  sides 


Fig.  175. — Showing  the 
vaginal,  perineal,  and  jicri- 
anal  suture  line  follow- 
ing proctectomy  by  the 
vaginal  route.  (Author's 
technic.) 


586      SURGICAL    TREATMENT    OF    THE    GASTRO-INTESTIXAL    TR.\CT 

and  anstomosing  the  upper  end  to  the  healthy  bowel  below — bilateral 
exclusion  (Fig.  177).  The  author  has  resorted  to  this  operation  many 
times  as  a  substitute  for  colostomy  and  resection  of  the  intestine  in  the 


Fig.  176.  —  Entero-anasto- 
mosis  with  ^SIurjDhy  button.  Per- 
formed for  the  rehef  of  volvu- 
lus and  ptosis  of  the  transverse 
colon.     (After  author's  case.) 


Fig.  177. — Bilateral  exclusion  for  irremovable 
cancer  of  the  descending  colon  after  the  ends  of 
the  diseased  segment  have  been  brought  to  the 
surface  for  drainage.     (Author's  case.) 


treatment  of  the  various  forms  of  catarrhal  and  specific  colitis,  ob- 
structive diarrhea,  and  intestinal  obstruction,  and  the  results  ha^'e  been 
entirely  satisfactory.     When  it  is  properly  and  quickly  performed  in- 


Fig.  178. — Intestinal  exclusion  for  cecal  cancer  with  adhesions  (ileocolostomy)  and  drain- 
age of  the  cecum.     (After  author's  case.) 


testinal  exclusion  is  not  dangerous,   brings  immediate  relief  \o  the 
patient,  and  often  effects  a  permanent  cure. 

In  cases  where  the  ileum  is  joined  to  the  colon,  sigmoid,  or  rectum 


INTESTINAL    EXCLUSION 


587 


{Ueocolostomy,  sigmoidostomy,  or  rectostomy)  the  stools,  which  are  fluid 
in  the  beginning,  gradually  become  fewer,  and  finally  normal  within 


Fig.  179. — Author's  methods  of  draining  or  dealing  with  the  diseased  bowel  when  it 
cannot  be  removed  following  exclusion:  A,  Cecostomy;  B,  blind  end;  C,  D,  F,  and  G, 
colonic  (colostomj- j ;  E,  appendicostomy. 

from  six  to  tw'elve  weeks.      The  author  has  in  several  instances  de- 
monstrated that  the  unused  bowel  does  not  become  useless,  but  func- 


Fig.  180. — Entero-anastomosis  (ileoproctostomy),  showing  author's  method  of  prevent- 
ing regurgitation  bj'  the  formation  of  acute  angulations  in  the  ileum.  Operation  per- 
formed for  the  relief  of  obsructive  adhesions  situated  at  the  hepatic  fle.Ture.  (.\fter 
author's  case.) 


tionates  normally  if  healed  when  continuity  of  the  intestine  has  been 
re-established  weeks  or  years  after  the  original  operation. 


588      SURGICAL    TREATMENT    OF    THE    GASTRO-INTESTIXAL    TRACT 

Regurgitation  has  been  successfully  prevented  by  the  author  both 
by  narrowing  the  adjacent  gut  with  a  ligature,  or  by  angulating  it^  with 
sutures  where  the  large  bowel  is  blocked  or  ulcerated  and  the  patient 
shows  evidences  of  intestinal  infection  or  auto-intoxication  (Fig.  i8o). 
Drainage  should  be  provided  for  through  an  appendicostomy  or  cecos- 
tomy  after  the  diseased  gut  has  been  excluded. 


Fig.  i8i. — Unilateral  exclusion  (ileiKolostuniy)  for  the  relief  of  a  strictured  lower 
ascending  colon.  The  ileum  is  seen  divided  and  both  ends  closed,  the  proximal  end 
being  joined  to  the  transverse  colon.  The  ascending  colon  has  been  divided,  and  one 
end  closed  and  the  other  left  open  (colostomy)  for  drainage. 


The  technic  of  intestinal  exclusion  has  been  fully  discussed  in 
Chapter  XXXV,  Gant's  Intestinal  Stasis  ("Constipation  and  Obstipa- 
tion"), where  many  cases  have  been  recorded,  hence  further  consider- 
ation of  the  subject  is  unnecessary  here. 

'  This  procedure  was  described  in  Gant's  Constipation  and  Intestinal  Obstruction 
(1909). 


NDEX 


Abscess,  hepatic,  364 

ischiorectal,  in  entamebic  colitis,  364 
perirectal,  in  entamebic  colitis,  364 
submucous,  in  entamebic  colitis,  364 
tropical,  364.     See  also  Hepatic  abscess. 

Abscesses  in  entamebic  colitis,  361 
in  tubercular  enteritis,  252 
metastatic,  in  entamebic  colitis,  361 

Achylia  gastrica,  diarrhea  in,  123 

Acid-poisoning,  diarrhea  in,  166 

Acids  in  entamebic  colitis,  380 

Acrodynia,  diarrhea  in,  67 

Actinomycosis,  diarrhea  in,  loi 
resembling  tubercular  enteritis,  259 

Acute  catarrhal  enteritis,  181 

Addison's  disease,  diarrhea  in,  171 

Adenoidism,  myxorrhea  coli  in,  463 

Age  in  entamebic  colitis,  327 

of  occurrence  in  tubercular  enteritis,  214 

Agglutinating  test  in  bacillary  colitis,  410, 
411 

Agoraphobia,  diarrhea  in,  117 

Albuminuria  in  tubercular  enteritis,  257 

Alcoholism,  diarrhea  in,  1 10 
treatment,  iii 

Alkali-poisoning,  diarrhea  in,  167 
treatment,  168 

A-Vmeba,  definition  of  genus,  7,33 

Amebse,  classification  of.  Calkins',  333 
Craig's,  335 
Hartmann's,  332 

and    Calkins',   points   of   difference, 

duration  of  life  and  resistance,  339 
morphology  of,  336 
motility  of,  338 
non-pathogenic,  325 
pathogenic,  325 
reproduction  of,  339 
Amcjcba  coli  discovered  by  Loesch,  323 
dysenteriie,  324 
histolytica,  324 
Amyloid  degeneration  of  intestine,  differ- 
ential diagnosis,  198 
resembling  tubercular  enteritis,  259 
Amyloidosis,  intestinal,  diagnosis,  71 
diarrhea  in,  69 
etiology,  69 
symptoms,  70 
treatment,  71 
Anal  fissure,  diagnosis,  509 

surgical  treatment,  517,  518 
sphincter,  hypertrojihy  of,  surgical  treat- 
ment, 517 


Anemia,  diarrhea  in,  108 

dirt-eaters',  427.     See  also  Uncinariasis. 

pernicious,  diarrhea  in,  109 
Anesthesia,  local,  in  surgical  treatment  of 

tubercular  enteritis,  285 
Anguillula  stercoralis,  436 
Ankylostoma  duodenale,  427 
Ankylostomiasis,    427.     See    also    Uncina- 
riasis. 
Anorectal  syphilis,  pathology,  302 
Anthrax,  diarrhea  in,  q6 
Antiseptic  remedies  for  entamebic  colitis, 
380 
for  tubercular  enteritis,  273-275 
Anus,  intestinal  irrigation  by,  471 
Appendicecostomy,  551 
Appendicitis,  catarrhal,  diagnosis,  195 

differential  diagnosis,  198 

differentiation    from    tubercular    hyjier- 
plastic  enteritis,  264 

entamebic.  in  entamebic  colitis,  361 

resembling  tubercular  enteritis,  245 
Appendicocecostomy,  545 

in  entamebic  colitis,  391 
Appendico-enterocecostomy,  Gant's,  570 
Appendicostomy,  545 

disadvantages  of,  565,  566 

for  diarrhea,  21 

for  sjqjhilitic  enteritis.  319 

Gant's,  technic  of,  567 

in  entamebic  colitis,  391 

in  tubercular  enteritis,  288 

mortality  from,  553 

Pettyjohn's  stab-wound,  571-573 

results  of  through-and-through  irrigation 
following,  552 

technic  of,  566 
Appendix,  involvement  of,  in   acute  enta- 
mebic colitis,  346 
in  hyperplastic  tubercular  enteritis,  233 
Arsenic-poisoning,  diarrhea  in,  163 

treatment,  164 
Arteriosclerosis,  diarrhea  in,  112 
Ascariasis,  431 

diagnosis,  432 

symi)toms,  431,  432 

treatment,  433 
Ascaris  lumbricoides,  431 

trichiurae,  435 
Astringent  remedies   in   entamebic   colitis, 
380 
in  myxorrhea  coli,  468 
Asylum  dysentery,  393,  400,  407,  413.    See 

also  Bacillary  colitis. 


590 


INDEX 


Bacillary  colitis,  393,  400,  407,  413 
absorption  of  toxins  in,  401 
agglutinating  test  in,  410.  411 
and  entamebic  colitis,  differential  diag- 
nosis. 409 
ascending  t\pe.  401 
blood  changes  in,  411 
.  catarrhal,  402 

sjTnptoms,  407 
caused  by  Bacillus  dysenteriae,  393 
classification  of  bacilli  concerned  in,  396 
complications,  40S 
descending  t>pe.  401 
diagnosis,  409 
diet  regulation  in,  414 
dysenteric,  397 
dj'senteroid,  397 
etiolog\-,  393 

examination  of  feces  in,  409 
fulminating  U-pe.  404 
histon,-.  393 
in  liver  abscess.  406 
intestinal  stenosis  In,  406 
mortalit}'  after  serum  therapy,  418 
pathologA,-,  400 

permanent  immunity  from,  418 
pseudomembranous,  405 
rest  treatment,  414 
sequela;,  408 

soothing  remedies  in,  419 
s>Tnptoms.  407 
topical  applications  in,  419 
treatment,  irrigating,  418 

local.  418 

medical,  414 

prophylactic,  413 

serum,  416 

supportive,  413 

surgical,  420 

vaccine,  416 
ulcerative,  402 
dysentery-,  393,  400,  407,  413.    See  also 
Bacillary  colilis. 
Bacillus  botulinus  in  decaj-ed  meat,  152 
coli  in  decayed  meat,  152 
dysenterise  cause  of  bacillar}'  colitis,  393 

table  of  characteristics,  398 
enteritidis  in  meat-poisoning,  152 
in  milk,  153 
Balantidic  colitis,  446 
diagnosis.  456 
from  infected  pork,  448 
geographic  distribution,  448 
histopathologA',  451-455 
in  orangoutangs.  447 
postmortem  findings  in,  451,  456 
prognosis.  457 
symptoms,  455 
treatment,  457 
ulceration  in.  452 
Balantidium  coli.  446 
cultivation  of.  448 
in  blood-vessels,  454 
in  feces.  450 
morphology' ,  449 
reproduction  of,  450 


Balantidium  minuteum,  446 

Beef  tapeworm.  424 

Bilharzia  haematobia,  438 

BiUar\-  insufficiency  in  gastrogenic  diarrhea. 

Bismuth     subcarbonate     in     Rontgen-ray 

diagnosis  of  cUarrhea,  52 
Blood  analysis  in  tubercular  enteritis,  258 

changes  in  bacillarj'  colitis,  411 
in  entamebic  colitis,  363 

examination  in  diarrhea,  42 
in  sj-philitic  enteritis,  310 

in  stools,  38 
Bothriocephalus  latus,  424 
Botulism,  toxemia  from,  152 
Bowel  perforation  in  entamebic  colitis,  362 

treatment,  direct,  in  diarrhea,  20 
Bums,  diarrhea  from,  116,  173 


C.'iCHExiA,  diarrhea  in,  108 
Calkins'  and  Hartmann's  classification    of 
ameba;.  points  of  diflerence,  333 

classification  of  amebte,  t,;^^ 
Cancer  and  h\-perplastic  tubercular  enteritis, 
differential  diagnosis,  263 

caused  bj'  s}"phiUtic  enteritis,  30S 
Canned  food  poisoning,  diarrhea  in,  155 
Carcinoma  and  fecal  impaction,  differential 
diagnosis,  105 

complicating  tubercular  enteritis,  254 

of  stomach,   gastrogenic  diarrhea  from, 
124 
Catarrhal  enteritis,  acute.  181 

chronic.  189 
Catheter  guide.  Gant's.  557,  558 
Cecal  involvement  in  tubercular  enteritis, 

212 
Cecostomy,  545 

appendiceal,  in  tubercular  enteritis,  288 

closure  of  opening  after,  550 

for  diarrhea,  21 

for  syphilitic  enteritis,  319 

Gant's,  556 

in  entamebic  colitis,  391 

in  tubercular  enteritis,  288 

mortality  from.  553 

technic  of.  554 

through-and-through  irrigation  following, 

Celiac  disease,  94 
Celioproctectomy,  584 

control  of  bleeding  in,  585 

preservation  of  sphincter  muscle  in.  585 
Cercomonas  hominis.  444 
Cerebrospinal  meningitis,  diarrhea  in,  1 13 
Cestodes,  423.      See  also  Taprdorms. 
Change  of  occupation  in  tubercular  enteritis, 

269 
Cheese-poisoning,  diarrhea  in,  153 

tyrotoxicon  in,  154 
Chicken-pea  poisoning,  158 
Children,  diseases  of,  enteritis  in,  179 

older,  formulae  for  diarrhea  in,  540 

young,  formulae  for  diarrhea  in,  539 
Chilling,  diarrhea  from,  118 


INDEX 


591 


Chilling,  diarrhea  from,  treatment,  119 
Chilodon  dentatus,  4|6 
Cholera,  diagnosis,  82 
diarrhea  in,  81 
prognosis,  83 
sporadic,  diagnosis,  85 
diarrhea  in,  84 
symptoms.  85 
treatment,  85 
treatment,  83 
winter,  diagnosis,  88 
etiology,  86 
mortality,  88 
pathology,  87 
symptoms,  87 
treatment,  88 
tjTDes,  87 
Choleriform  diarrhea,  84 
Cholerine  diarrhea,  84 
Chronic  nephritis,  diarrhea  in,  62 
Cihates,  446 
Cladorchis  watsoni,  442 
Classification  of  amebie,  ;i^^ 
of  bacilli  concerned  in  bacillary  colitis, 

396 
of  diarrheas,  21 

etiologic,  22,  23 
of  entamebic  colitis,  357 
of    entamebae,    332.       See    also   Amebce, 

classification  of. 
of  tubercular  enteritis,  219 
Claviceps  purpurea,  158 
Clay  bolus  treatment  of  chronic  enteritis, 

208 
Clifton  Springs  pack  for  chronic  enteritis, 

209 
Climate  and  entamebic  colitis,  329 
Clothing,    proper,    in    tubercular   enteritis, 

269 
Coccidia,  457 

Coccidium  bigeminum,  457 
cuniculi,  457 
hominis,  457 
Coccygeal  deformity,   treatment,   surgical, 

518         ..       " 
Cochin-China  diarrhea,  pathology,  93 

symptoms,  93 
Cochinchinitis,  92 
Cold  beverages,  diarrhea  from,  119 
Colic  and  enteric  catarrh,  differentiation, 

.^95      . 
differential  diagnosis,  198 
entamebic   chronic,   collar-button   ulcers 

in, 350 
in  myxorrhea  coli,  465 
in  sj-]3hilitic  enteritis,  305 
Colica  mucosa,  183,  460.     See  also  Myxor- 
rhea coli. 
Colitis,  174,  186,  200.    See  also  Enteritis. 
bacillary,  393,  400,  407,  413.     See  also 

Bacillary  colitis. 
balantidic,  446   See  also  Balantidic  colitis. 
chronic,  formulse  for,  535 
entamebic,  321,  341,  356,  370,  377.     See 

also  Entamebic  colitis. 
fever  in,  194 


Colitis,  gonorrheal,  458.      See  also  Gonor- 
rheal colitis. 

helminthic,    422.      See    also    Helminthic 
colitis. 

localization,  193 

membranous,  differential  diagnosis,  198 

mucoid  dejecta  in,  194 

neuroses  in,  194 

parasitic,  422,  444.     See  also  Helminthic 
colitis. 

protozoal,  444 

syphihtic,  294,  304,  313.    See  also  Syph- 
ilitic enteritis. 

tubercular,  211,  219,  240,  255,  266,  285. 
See  also  Tubercular  enteritis. 
Collar-button  ulcers  in  chronic  entamebic 

colitis,  350 
Colon,  involvement  of,  in  tubercular  enteri- 
tis, 239 
Colonic  dilatation,  diagnosis,  507 

exclusion  in  entamebic  colitis,  391 

inflation  for  diagnosis  of  diarrhea,  29 
rectal  tube  for,  31 
Coloptosis,  surgical  treatment,  515 
Colostomy,  552 

Gant's,  576-578  _ 

in  entamebic  colitis,  391 

in  tubercular  enteritis,  288 

technic  of,  575 
Compensator^'  cliarrhea,  170 

treatment,  173 
Congenital    deformities    of  large  intestine, 

diagnosis,  504 
Constipation,    chronic    obstructive,    symp- 
toms, 496 

enteritis  in,  180 

fragmentary,  17,  21 

in  enteritis,  188 

in  helminthic  colitis,  422 

in  myxorrhea  coli,  465 

in  tubercular  enteritis,  243 
Contagious  diseases,  acute,  diarrhea  in,  72, 

79 
Coprostasis,  enteritis  in,  180 

Coprostatic  diarrhea,  103 

diagnosis,  105 

prognosis,  105 

symptoms,  104 

treatment,  105 
Cravat  clamps  in  Cant's  cecostomy.  559, 

564 
Culture  of  entameba\  331 
Cysticerci  in  measly  pork,  424 

Davidson's  syringe,  473 
Dermatobia  cyaniventris,  98 
Diabetes,  diarrhea  in,  171 
mellitus,  diarrhea  in,  63 
Diagnosis,  dilTcrential,  of  amj-loid  degenera- 
tion of  intestine,  198 
of  ajjpendicitis,  108 
of  benign  tumors  of  intestine,  199 
of  catarrhal  enteritis,  197 
of  colic,  198 

of  entamebic  colitis  and  bacillary  colitis, 
409 


592 


INDEX 


Diagnosis,  differential,    of    enteritis   from 
burns,  199 

of  fecal  impaction  and  carcinoma,  105 

of  gastrogenic  and  enterogenic  dyspep- 
sia, 199 

of    hN-perplastic    tubercular    enteritis, 
262,  263 

of  infectious  diseases  of  intestine,  198 

of  malignant  intestinal  tumors,  199 

of  neurogenic  diarrhea,  198 

of  pancreatic  bowel  disturbances,  198 

of  peritonitis,  198 

of  ptomain-poisoning,  197 

of  tubercular  and  sj-philitic  enteritis. 
308 

of  tj-phoid  fever,  197 
general,  of  tubercular  enteritis,  255 
of  ascariasis,  432 
of  bacillar}-  colitis.  409 
of  balantidic  colitis,  456 
of  cholera,  82 
of  colonic  dilatation,  507 
of  congenital  deformities  of  intestine,  504 
of  diarrhea,  24 

alba.  94 

coprostatic.  105 

enterogenic.  134 

fluoroscope  in.  51 

gastrogenic,  126 

in  e\'e  diseases.  34 

in  liver  diseases.  59 

in  mouth  diseases.  55 

in  nasophar>-ngeal  diseases,  55 

in  pancreatic  diseases,  61 

in  suprarenal  diseases,  64 

in  thyroid  diseases.  57 

neurogenic,  144 

Rontgen  ray  in,  48 
of  enlarged  colonic  sacculations,  506 

rectal  valves.  508 
of  entamebic  colitis.  370 
of  enterogenic  diarrhea.  134 
of  enteroperitoneal  tuberculosis,  256 
of  enteroptosis,  507 
of  enterospasm.  508 
of  extra-intestinal  pressure,  505 
of  fecal  impaction.  505 
of  gastrogenic  diarrhea,  126 
of  gonorrheal  colitis,  459 
of  hemorrhoids,  509 
of  hepatic  abscess,  368,  373 
of  Hirschsprung's  disease,  507 
of  hyperplastic  tubercular  enteritis,  260 

invoU-ing  peritoneum.  265 
of  hj^pertrophy  of  levator  ani,  509 

of  O'Beime's  sphincter,  508 

of  sphincter  ani.  509 
of  internal  hemiae.  507 
of  intestinal  adhesions,  505 

affections,  lavage  in,  41 

amyloidosis.  71 

calculi.  505 

diverticula 

parasite: 

strictures.  505 

tumors,  505 


3"0 

io8 


Diagnosis  of  intestinal  \ol\ulus,  505 

of  mesenteric  disease.  507 
embolism,  527 

of  milk-poisoning,  153 

of  m\"xorrhea  coh,  466 

of  obstructive  diarrhea,  504 

of  ox>'uriasis,  434 

of  pericolitis,  506 

of  perisigmoiditis,  506 

of  peritoneal  tuberculosis,  265 

of  postoperative  diarrhea,  522 

of  ptomain-poisoning.  159 

of  rectocele.  506 

of  schistosomiasis,  440 

of  splanchnoptosis.  507 

of  sporadic  cholera.  85 

of  sprue,  93 

of  strong^loidosis,  436 

of  sj-philitic  enteritis,  307 

Spirochieta  pallida  in,  308 
test-meals  in,  310 
^^'assermann  reaction  in,  308 

of  teniasis,  425 

of  trichuriasis,  436 

of  ulcerative  tubercular  enteritis,  256 

of  imcinariasis,  430 

of  winter  cholera ,  88 

of  yellow  fever.  79 
Diarrhea  adiposa.  61 

alba,  94 

cathartica,  115 

chylosa,  94 

noctuma,  121 
Diarrheal  diseases,  surgical  treatment   542, 

545-  556-  574 
Diazo-reaction  in  tubercular  enteritis,  258 
Diet,  control  of.  in  acute  enteritis,  201 
in  chronic  enteritis,  203,  204 
in  m^'xorrhea  coli,  467 
in  tubercular  enteritis,  270 
regulation  in  bacillan.-  colitis,  414 
Dietar\"  indiscretions,  enteritis  from.  176 
Digital  examination  in  diarrhea,  46 
Diphtheria,  diarrhea  in.  75 
Diplococcus    pneumoniae    in    hemorrhagic 

enteritis.  182 
Dirt-eaters'  anemia.  427.    See  also  Uncina- 
riasis. 
Distoma  haematobium.  438 
Diverticula,  obstructive  diarrhea  from.  500 

of  colon,  surgical  treatment.  515 
Drug  addiction  from  treatment  of  diarrhea, 

20 
Duodenal  involvement  in  tubercular  enteri- 
tis. 212 
ulcer.  133 

and  gastric  ulcer,  differentiation.  135 
differentiation  from  tubercular  enteri- 
tis. 259 
in  enterogenic  diarrhea.  133 
treatment,  136 
Duodenitis,  localization  of,  192 
Dysenten.-.  asylum.  393.  400,  407,  413.    See 
also  Bacillary  colitis. 
bacillarv',  393.  400,  407.  413.     See  also 
Bacilhry  colitis. 


INDEX 


593 


Dysentery,  differentiation  from  tubercular 
enteritis,  260 
entumebic,  321,  341,  356,  370,  377.    See 

also  Entamebic  colitis. 
helminthic,    422.      See    also    Helminthic 

colitis. 
protozoal,  444 
true,  395 
Dysj)epsia,  ent erogenic,  enteritis  in,  178 
fermentatixe,  in  gastrogenic  diarrhea,  127 
gastrogenic  and  cnterogenic,  differential 
diagnosis,  iqq 
Dj'spejitic  acid  diarrhea,  134 

diarrhea,  123,  132.    See  also  Enterogenic 
diarrhea. 


Eczema,  acute,  diarrhea  in,  67 
Einhorn's  duodenal  tubes,  53 
food-carrying  cups,  53 
obturators,  53 
stomach  bucket,  32 
test-beads,  53 
El  Bicho  diarrhea,  99 
Electricity  for  chronic  enteritis,  205 
Electrode,  hydriatic,  473 
Embolism,  mesenteric,  526 
Emetin  in  entamebic  colitis,  382 
Emulsions  used  in  intestinal  irrigation,  477 
Enema  tubes,  478 
Enemata,  470 

amount  of  fluid  used,  472 
in  acute  enteritis,  202 
Entameba,  definition  of  genus,  335 
EntamebiE,  classiiication  of,  332.    See  also 
A  mcbcB,  classification  of. 
culture  of,  331 

duration  of  life  and  resistance,  339 
morphology  of,  336 
motiUty  of,  338 

reproduction  by  schizogony,  339 
by  simple  division,  339 
within  cyst,  339 
Entamebiasis,  321,  341,  356,  370,  377.    See 

also  Entamebic  colitis. 
Entamebic  colitis,  321,  341,  356,  370,  377 
abscesses  in,  361 
acids  in,  380 

acute,  appendiceal  involvement  in,  346 
pathology,  344-346 

of  pre-ulcerative  stage,  347 
adhesions  in,  362 
age  in, 327 

and  bacillary  colitis,  differential  diag- 
nosis, 409 
angulations  in,  362 
antiseptic  remedies  in,  380 
appendicocecostomy  in,  391 
astringent  remedies  in,  380 
atrophy  in,  362 
blood  (  hangcs  in,  363 
bowel  i)erforation  in,  362 
carried  by  flies,  329 

by  incHviduals,  328 
caused  by  Entamoeba  histolytica,  323 
cecostomy  in,  391 

38 


Entamebic     colitis,     chronic,     destructive 
stage,  351 
Harris'  ulcers  in,  349 
jjathology,  346 

of  ulcerative  stage,  348 
stellate  ulcers  in,  349 
symptoms,  360 
undermined  ulcers  in,  350 
classes  of  ])eople  infected,  327 
classification  of,  357 
colonic  exclusion  in,  391 
colostomy  in,  391 
complications  of,  361 
definitions,  321 
diagnosis,  370 
effect  of  climate  in,  329 
emetin  in,  38 2 

entamebic  appendicitis  in,  361 
enterostomy  in,  391 
etiology,  326 
examination  of  lesions  at  autopsy,  373 

of  stools  in,  371 
fistulce  in,  361 
from  fresh  vegetables,  326 
gastro-intestinal  disturbances  in,  363 
geographic  distribution,  330 
hemorrhage  in,  362 
history  of,  323-326 
in  war,  328 
ipecacuanha  in,  381 
irrigation  in,  383 
ischiorectal  abscess  in,  364 

fistulae  in,  364 
location  and  distribution  of  lesions,  341- 

344 
metastatic  abscesses  in,  361 
occupation  in,  327 
organisms     associated     with     specific 

agents  of,  322 
pathology,  341,  344-346 
perirectal  abscess  in,  364 

fistula  in,  364 
prognosis,  374 
racial  predisposition  in,  327 
rectal  complications  in,  363 

strictures  in,  364 

ulcers  in,  364 
relief  of  tenesmus  in,  379 
resection  and  amputation  in,  391 
salts  of  quinin  for,  549 
sex  in,  327 

skin  affections  in,  362 
small  intestine  in,  363 
stenosis  in,  362 
submucous  abscess  in,  364 

fistuhe  in,  364 
surgical  procedures  in,  391 
symptoms,  356,  360 

of  aggravated  t3^)e,  358 

of  diphtheric  type,  359 

of  gangrenous  U'pe,  359 

of  latent  types,  356 

of  mild  tyjje,  357 

of  moderately  severe  tj-pe,  357 
tonics  in,  380 
topical  applications  in,  383,  388 


594 


INDEX 


Entamebif  colitis,  treatment,  376 
dietetic,  377 
local,  383 

irrigants  in,  386 
medical,  379 
prophylactic,  376 
supportive,  377 
surgical,  389-391 

tlirough-and-through  irrigation  in, 
390 
ulcers  of,  healing  tendencies,  355 

microscopic  appearance,  353 
urinary  changes  in,  363 
dysenterj%  321,  341,  356,  370,  377.     See 

also  Entamebic  colitis. 
hepatic  abscess,  364.     See  also  Hepatic 
abscess. 
Entamceba  coli,  325 

diagram  of  life  cj-cle,  340 
histolytica,  92 

cause  of  entamebic  colitis,  323 
Schaudinn's   demonstration  of   patho- 
genicity of,  325 
hominis,  2,2s 
tetragena,  325 
Enterectomy,  578-582 
technic  of,  580-582 
Enteric  catarrh   and  colic,  differentiation, 

Enteritis,  174,  186,  200 

abdominal  examination  in,  196 
acute  catarrhal,  181 

macroscopic  appearance,  182 
microscopic  appearance,  181 
dietar\'  control  in,  201 
enemata  in,  202 
rest  in  bed  for,  201 
treatment,  200 
medical,  201 
catarrhal,  differential  diagnosis  of,  197 
chronic  catarrhal.  189 

objective  symptoms,  190 
intestinal  inflation  for,  209 
irrigation  for,  207 
massage  for,  204 
medical  treatment,  205 
mineral  waters  for,  205 
opotherapy  in.  208 
organotherapy  in,  208 
pathology,  184 
treatment,  202 
by  clay  bolus.  208 
by  Clifton  Springs  pack,  209 
dietetic,  203,  204 
electric,  205 
medical,  205 
Rosenberg  dry,  208 
surgical,  208 
vaccines  for,  208 
vibration  for,  204 
constipation  in,  188 
crouposa  endemica,  183 

necrotica,  diarrhea  in,  112 
diagnosis,  iqo 
digital  examination  in,  196 
diphtheritica,  183 


Enteritis,   d3'speptic,   differentiation    from 

tubercular  enteritis,  260 
enterospasm  in,  188 
etiology,  176,  177 
examination  of  blood  in,  196 

of  dejecta  in,  187 
fever  in,  188 
follicular,  183 
fermenting  stools  in,  197 
from  burns,  differential  diagnosis,  199 
from  chemicals,  179 
from  dietar>'  indiscretions,  177 
from  intestinal  obstruction,  179 
from  mechanical  irritants,  179 
from  medicines,  179 
Gmelin's  reaction  in,  188 
green  stools  in,  197 

hemorrhagic,  Diplococcus  pneumoniae  in, 
182 

resemblance  to  typhoid,  182 
hepatogenic  disorders  in,  178 
in  children's  diseases,  179 
in  constipation,  180 
in  coprostasis,  180 
in  enterogenic  dyspepsia,  178 
localization  of.  191 
membranacea,  183 
mucoid  stools  in,  188 
nausea  in.  188 
nodularis.  184 
obstipation  in,  188 
ocher-colored  stools  in,  197 
pancreatogenic  disorders  in,  178 
pathology.  181 

proctosigmoidoscopic  examination  in,  196 
prognosis,  209 
putrefj'ing  stools  in,  197 
specific  bacteria  causing,  175 
steatorrhea  in,  188 
symptoms,  186 
syphilitic,  294,  304,  313.     See  also  Syh- 

ilitic  enteritis. 
tubercular,  211,  219,  240,  255,  266,  285. 

See  also  Tubercular  enteritis. 
vomiting  in,  188 
Enterocecostomy  for  diarrhea,  21 

for  svphilitic  enteritis,  319 
Enterocolitis,    174,    186,    200.      See    also 

Enteritis. 
s\'philitic,  204,  304,  313.    See  also  Syph- 
ilitic enteritis. 
Enteroclysis,    470.      See    also    Irrigation, 

intestinal. 
Enterogenic    and    gastrogenic    dyspepsia, 

diff"erential  diagnosis,  199 
diarrhea,  132 

diagnosis,  134 

symptoms,  133 

treatment,  135 
disturbances  in  myxorrhea  coli,  462 
dyspepsia,  enteritis  in,  17S 
Enteroperitoneal  tuberculosis,  diagnosis,  256 

symptoms,  241 
Enteroptosis,  diagnosis.  507 
obstructi\-c,  diarrhea  in,  494 
surgical  treatment,  515 


IND]iX 


595 


Enterospasm,  diagnosis,  508 
in  enteritis,  188 
in  helminthic:  colitis,  422 
in  syphilitic  enteritis,  306 
obstructive  diarrhea  in,  495,  499 
surgical  treatment,  516 
Enterostomy,  552 

in  entamebic  colitis,  391 
technic  of,  574 
Eosinophilic  diarrhea,  121 
Epilepsy,  neurogenic  diarrhea  in,  143 
lirgotismus,  158 
Erysipelas,  diarrhea  in,  go 
Er>-thema  exudativum  multiforme,  diarrhea 
in,  67 
nodosum,  diarrhea  in,  67 
Examination,  abdominal,  in  enteritis,  196 
digital,  in  enteritis,  iq6 

of  rectum  in  syphiUtic  enteritis,  311 
in  diarrhea,  24 
in  syphilitic  enteritis,  proctoscopic,  310 

sigmoidoscopic,  310 
of  blood  in  diarrhea,  42 
in  enteritis,  196 
in  syphilitic  enteritis,  310 
of  feces,  36-40 

in  bacillary  colitis,  409 
in  entamebic  colitis,  371 
in  helminthic  colitis,  443 
in  sj'philitic  enteritis,  309 
macroscopic,  37 
microscojjic,  39 

pathologic  significance  of,  40 
of  intestine  in  syphilitic  enteritis,  macro- 
scopic, 310 
microscopic,  310 
of  lesions  of  entamebic  colitis  at  autopsy, 

373 
of  stomach  contents  in  diarrhea,  31 
of  urine  in  diarrhea,  41 

in  enteritis,  196 
proctosigmoidoscopic,  in  enteritis,  196 
rectal,  Sims'  posture  for,  25 
Exclusion,  intestinal,  for  syphilitic  enteritis. 

319. 
statistics  of,  290 
of  bowel  in  tubercular  enteritis,  bilateral, 
286 
unfavorable  features,  287 
unilateral,  2S6 
Exercise  in  tubercular  enteritis,  268 
Exophthalmic  goiter,  diarrhea  in,  56,  172 
Eye  diseases,  diarrhea  in,  54 


Fasciolata  ilocana,  442 
Fasciolopsis  buskii,  442 

fulleborni,  442 
Fecal  impaction  and  carcinoma,  differential 
diagnosis  of,  105 
diagnosis,  505 
surgical  treatment,  513 
Feces,  examination  of,     36-40.       See    also 

Stools. 
Fever,  control  of,  in  tubercular  enteritis, 
277 


Fibrinomembranous      partitions,      surgical 

treatment,  511 
Filaria  sanguinis  hominis,  94 
Fish  tapeworm,  424 
Fish-]:)oisoning.  diarrhea  in,  154 
Fistulae  in  entamebic  colitis,  361 
ischiorectal,  364 
perirectal,  364 
submucous,  364 
in  tubercular  enteritis,  252 
Flagellates,  444 

Flatus  in  sjq^hilitic  enteritis,  306 
Flies  as  carriers  of  entamebic  colitis,  329 
Fluke- worms,  437 

Fluoroscopic  diagnosis  of  diarrhea,  51 
Foreign  bodies,  surgical  treatment,  512 
Formula;  for  chronic  colitis,  535 
diarrhea,   535 
for  diarrhea  in  infants,  539 
in  older  chiklren,  540 
in  young  children.  539 
for  helminthic  c:olitis,  537 
Formulary,  529-541 
Fragmentary'  constipation,  21 
Fresh  air  for  tubercular  enteritis,  268 

vegetables,  entamebic  colitis  from,  326 
Functional  diarrhea,  138.     See  also  Neuro- 
genic diarrhea. 


G.\xt's  anal  douche,  477 

appendiceal  irrigator,  568,  569 
appendico-enterocecostomy ,  5  70 
appendicostomy,  steps  of,  568,  569 

technic  of,  567 
catheter  guide,  557.  558 
cecostomy,  556 

advantages  of,  564 

comments  on,  563 

cravat  clamps  in,  559,  564 

indications  for,  562 

method  of  burying  catheter  in,  563 

steps  of,  557-550 
colostomy,  576-578 
double-flow  irrigating  proctoscope,  485 
enterocecostomy,   556.     See  also  Gant's 

cecostomy. 
enterocolonic  irrigator,  560.  561 
funnel  proctoscope  for  intestinal  irriga- 
tion, 482 
technic  for  passing  colon-tube.  4S6 
Gas  distention  in  tubercular  enteritis,  244 
Gas-pipe  intestine,  301 
Gastric  diagnosis,  stomach-tube  for,  33 
lavage,  129 
operations,  jjostoperative  diarrhea  after, 

5-°  .     . 

ulcer  and  duodenal  ulcer,  differentiation, 

135 
dilTerentiation  from  tubercular  enteri- 
tis, 259 
Gastrodiaphany,  35 
Gastrodiscus  hominis,  442 
Gastrogenic  and  enterogenic  dyspepsia,  dif- 
ferential diagnosis,  199 
diarrhea,  123 


596 


INDEX 


Gastrogenic  diarrhea,  atonic  type,  1 24 
biliary  insufficiency  in,  127 
deficient  motility  tj'pe,  124 
diagnosis,  126 

fermentative  dyspepsia  in,  127 
from  carcinoma  of  stomach,  124 
treatment,  128 
palliative,  130 
surgical,  131 
disturbances  in  mj'xorrhea  coli,  462 
Gastro-intestinal  disturbances  in  entamebic 

colitis,  363 
Gastroscopy,  35 

Gelatin  for  intestinal  irrigation,  480 
Genital  diseases,  diarrhea  in,  64 

male,  diarrhea  in,  66 
Genupectoral  posture  for  proctoscopy,  44 
Glanders,  diarrhea  in,  97 
Glandular    tuberculosis,    irrigating    treat- 
ment, 279 
Gmelin's  reaction  in  enteritis,  18S 
Gonorrhea,  intestinal,  458.    See  also  Gonor- 
rheal colilis. 
Gonorrheal  colitis,  458 
diagnosis,  459 
in  pederasts,  458 
patholog}-,  458 
symptoms,  45S 
treatment,  459 
proctitis,  458.    See  also  Gonorrheal  colitis. 
Gout,  diarrhea  in,  113,  171 
Gummata  of  intestine,  pathology,  299 


Hanes'    coal-oil    treatment    of    entamebic 

colitis.  387 
Harris'  ulcers  in  chronic  entamebic  colitis, 

349 
Hartmann's  and  Calkins'  classification  of 
amebae,  points  of  difference,  333 
classification  of  amebae,  ^,^,2 
Heat-stroke,  diarrhea  from.  120 
Helminthiasis,   422.      See   also   Helminthic 

colitis. 
Helminthic  colitis,  422 
constipation  in,  422 
enterospasm  in,  422 
examination  of  feces  in,  443 
formulae  for,  537 
obstipation  in,  422 
d3'senter3\  422.        See    also    Helminthic 
colitis. 
Hemorrhage  in  entamebic  colitis,  362 

in  mesenteric  embolism,  527 
Hemorrhoids,  diagnosis,  509 

surgical  treatment,  517 
Hepatic  abscess,  diagnosis,  368,  373 

entamebic,  364.        See     also     Hepatic 

abscess. 
histopathology,  366 
location  of,  365 
microscopic  appearance,  367 
number  of,  365 
prognosis,  374 
routes  of  infection,  364 
size  of,  365 


Hepatic  abscess,  symptoms,  368 

table  illustrating  site  of  rupture,  366 
treatment,  392 
surgical,  392 
Hepatogenic  disorders  in  enteritis,  178 
Heterophyes,  442 
Hill-diarrhea,  94 

Hirschsprung's  disease,  diagnosis,  507 
Histor)-  taking  in  diarrhea,  24 
Hookworm  disease,  427.    See  also  Uncina- 
riasis. 
Hot  water  for  intestinal  irrigation,  474 
Hydriatic  electrode,  473 
Hydrotherapy  for  chronic  enteritis,  205 
Hj-peracidity  diarrhea,  124 
Hypersensitive  areas,  neurogenic  diarrhea 

from,  144 
Hj'pertrophy   of     anal   sphincter,   surgical 
treatment,  517 
of   O'Beirne's   sphincter,   surgical   treat- 
ment, 516 
of  rectal  valves,  surgical  treatment,  516 
Hypodynamia  cordis,  diarrhea  in,  116 
Hysteria,  neurogenic  diarrhea  in,  144 

ICE-CRE.\ii  poisoning,  diarrhea  from.  153 
Ice-water  for  intestinal  irrigation,  474 
Ileac  involvement   in   tubercular  enteritis, 

212 
Ileitis,  localization.  102 
Ileocecal  catarrh,  diagnosis,  195 
Ileocolectomy.  statistics  of,  289 
Immunitv.  permanent,  from  bacillarv  colitis, 

418 
Imperforate  anus,  surgical  treatment,  511 
Infants,  formulae  for  diarrhea  in.  539 
Infarction,  intestinal,  526.    See  also  Mesen- 
teric embolism. 
Infectious  diseases,  acute,  diarrhea  in,  72, 

.79 
miscellaneous,  diarrhea  in,  91 
Inflammator>-  diseases,  surgical  treatment, 

542-  545-  556.  574  _ 
Inflation  of  intestine  in  chronic  enteritis,  209 
Influenza,  diarrhea  in,  75 

neurogenic  diarrhea  in,  143 
Inspection  of  patient  in  diarrhea,  26 
Internal  hernia;,  diagnosis.  507 
Intestinal  adhesions,  diagnosis.  505 
surgical  treatment,  513 
affections,  lavage  in  diagnosis,  41 
amyloidosis,  6q 
auto-intoxication,  neurogenic  diarrhea  in, 

143 

calculi,  diagnosis,  505 

catarrh,  non-specific,  174.     See  also  En- 
teritis. 

diverticula,  diagnosis,  505 

exclusion,  ^8^-588 
bilateral  586 
unilateral,  588 

gonorrhea,  458.       See    also    Gonorrheal 
colitis. 

infarction,  526.     See  also  Mesenteric  em- 
bolism. 


INDEX 


597 


Intestinal  irrij^Mtion,  470 

myiasis,  diarrhea  in,  98 

neoplasms,  obstrurli\e  diarrhea  from,  499 

obstruction,  enteritis  from,  179 

from  parasites,  surgical  treatment,  516 

[Kirasitcs,  diagnosis,  508 

obstructiv'e  diarrhea  from,  499 

schistosomiasis,  440 

stenosis  in  l)a(illar>'  colitis,  406 

operati\'e  treatment,  statistics  of,  291 

strictures,  diagnosis,  505 

obstructive  diarrhea  from,  498 
surgical  treatment,  512 

syi)liilis,  294,  304,  313.     See  also  Syphil- 
ilic  enteritis. 

tuberculosis,  211,  219,  240,  255,  266,  285. 
See  also  Tubercular  enteritis. 

tumors,  diagnosis,  505 
surgical  treatment,  512 

ulcers,  syphilitic,  298-301 

volvulus,  diagnosis,  505 
Intestine,  amyloid  degeneration  of,  differ- 
ential diagnosis,  198 

gummata  of,  pathology,  299 

infectious  diseases  of,   differential   diag- 
nosis, 198 

small,  in  entamebic  colitis,  363 

stricture  of,  pathology,  299-301 

tubercular  ulcer  of,  characteristics,  222 
Invagination,    obstructive    diarrhea    from, 

Involuntary  bowel  movements  in  neurogenic 

diarrliea,  144 
lodipin  in  syphilitic  enteritis,  316 
Tjjecacuanha  in  entamebic  colitis,  ^^,^^1 
Irregularities  of  li\ing,  diarrhea  from,  114 
Irriganls  in  local  treatment  of  entamebic 

colitis,  386 
used  in  intestinal  irrigation,  472 
Irrigation  in  chronic  enteritis,  207 
in  entamebic  colitis,  383 
in  myxorrhca  coli,  468 
intestinal,  470 

amount  of  fluid  used,  472 
of  oil  used,  479 

apparatus  for,  482-487 

by  anus,  471 

electrification  of  irrigant  in,  487 

emulsions  used  in,  477 

frecjuency  of,  472 

Gant's  funnel  proctoscope  for,  482 

gelatin  for,  480 

hot  water  for,  477 

ice-water  for,  474 

irriganls  used  in,  473 

limitations  of,  473 

medical  agents  used  in,  474-477 

oils  used  in,  477 

positions  for,  481 

teclinic  for,  480 

Ihrough-and-through.  471 

through  artificial  opening,  471 
Irrigator,  Gant's  appendiceal,  568,  569 

enterocolonic,  560,  561 
Ischiorectal  abscess  and  tubercular  enteritis, 
245 


Jamison's  seat  syringe,  479 

Jejunal  involvement  in  tubercular  enteritis, 

212 
Jcjunitis,  localization  of,  192 
Jelk's  formalin-boric  solution  in  treatment 

of  entamebic  colitis,  387 


Kidney  diseases,  diarrhea  in,  62,  172 


Lamhlia  intestinalis,  444 

Lardaceous    degeneration,    69.     See    also 

A  myloidosis,  intestinal. 
Lathyrismus,  158 
Lavage,  gastric,  129 

in  diagnosis  of  intestinal  affections,  41 
Leacl-|)oisoning,  diarrhea  in,  lOO 
Leukemia,  diarrhea  in,  109 
Levator  ani,  hypertrophy,  diagnosis,  509 
Lienteric    diarrhea,    123,    132.      See    also 

Enter ogcnic  diarrhea. 
Life-cycle  of  Entama.'ba  coli,  340 
Liver  abscess  in  bacillary  colitis,  406 

diseases,  diarrhea  in,  59 
Loesch's  discovery  of  Ama-ba  coli,  323 
Lumbricoid  worms,  431 


Maidismus,  diarrhea  in,  158 
Malaria,  diarrhea  in,  78,  96 
Marasmus,  diarrhea  in,  112 
Massage  for  chronic  enteritis,  204 
Measles,  diarrhea  in,  74 
Meat-poisoning,  diarrhea  from,  150 
Mechanic  diarrhea,  122,  488,  496,  504,  510. 

See  also  Obstructive  diarrhea. 
Medicinal-chemical  poisoning,  163 
Melena  in  sy^^hilitic  enteritis,  309 
Membranous  enteritis,  460.    See  also  .IA'A"- 

orrliea  coli. 
Mercurial  poisoning,  diarrhea  in,  165 
treatment,  165 
l)reparations  in  s>q:)hilitic  enteritis,  317 
Mercury  and  j)otassium  indid  in  sy[)iiiiitic 

enteritis,  315 
Mesenteric  disease,  diagnosis,  507 
embolism,  526 
diagnosis,  527 
etiology,  526 
hemorrhage  in,  527 
pathology,  526 
prognosis,  528 
symptoms,  527 
treatment,  528 
thrombosis,    526.      See    also    Mesenteric 
embolism. 
Methemoglobinemia,  diarrhea  in,  1 13 
Migraine,  neurogenic  diarrhea  in,  144 
Milk,  Bacillus  enteritidis  in,  153 

products,  poisoning  from,  diarrhea  in,  153 
Milk-poisoning,  diagnosis,  153 

diarrhea  in,  152 
Mineral  waters  for  chronic  enteritis,  205 
Miscellaneous   jioisons,    chemical,   diarrhea 
from,  168 


598 


INDEX 


Miscellaneous  poisons,  medicinal,  diarrhea 

from,  1 68 
Mortality  in  bacillar\-  colitis.  418 
IMouth  diseases,  diarrhea  in,  54 
Mucus  in  stools,  38 
IMuscarin  poisoning,  diarrhea  in,  157 
]\lushroom  poisoning,  diarrhea  in,  157 
ilyiasis,  intestinal,  diarrhea  in,  98 

sjTnptoms,  99 

treatment,  99 
^lyxorrhea  coli,  183,  460 

colic  in,  465 

constipation  in,  465 

diagnosis,  466 

diet  in,  467 

enterogenic  disturbances  in,  462 

etiology,  460-465 

from  surgical  conditions,  463,  464 

gastrogenic  disturbances  in,  462 

history  of,  460 

in  adenoidism,  463 

in  thj-roidism,  463 

irrigation  in,  468 

mucoid  evacuations  in,  465 

nervous  phenomena  in,  460 

nomenclature  of,  460 

pathology-,  465 

prognosis,  469 

symptoms,  465 

treatment,  466 
astringent,  468 
surgical,  468 
colica,  460.     See  also  Myxorrliea  coli. 
membranacea.  460.     See  also    Myxorrhea 

coli. 

Xasopharyxgeal  diseases,  diarrhea  in.  55 

Necator  americanus,  427 

Nematodes,  427 

Neosalvarsan  in  sjT^hilitic  enteritis.  315 

Neurasthenia,  neurogenic  diarrhea  in,  144 

Neurogenic  diarrhea.  121,  138 

diagnosis,  144 

differential  diagnosis.  198 

from  hypersensitive  areas,  144 

in  epilepsy,  143 

in  hysteria,  144 

in  influenza,  143 

in  intestinal  auto-intoxication,  143 

in  migraine,  144 

in  neurasthenia.  144 

in  tabes  dorsalis.  143 

involuntary-  bowel  mo\'ements  in,  144 

reflex  disturbances  in,  142 

sjTnptoms.  144 
Night-sweats  in  tubercular  enteritis,  treat- 
ment, 278 
Nocturnal    diarrhea.    57,    13S.      See    also 

NcMvogcn  ic  diarrhea . 
Nyctotherus  africanus,  446 
faba,  446 
giganteum,  446 

O'Beirne's  sphincter,  hypertrophy  of,  diag- 
nosis, 508 
obstructive  diarrhea  from,  495,  503 


O'Beirne's  sphincter,  hypertrophy  of,  sur- 
gical treatment.  516 
Obesity,  diarrhea  in,  106 

treatment.  106 
Obstipation  in  enteritis,  188 
in  helminthic  colitis,  422 
in  tubercular  enteritis,  243 
Obstructive  diarrhea,  21.  48S,  496,  504,  510 
chronic,  sj-mptoms.  496 
description,  488 
diagnosis,  504 
enterospasm  from,  499 
etiology,  490 
from  adhesions,  402 
from  colonic  malformation,  493 
from  congenital  deformities.  491 
from  disease  of  mesentery,  494 
from  diverticula,  500 
from  extra-intestinal  pressure,  491 
from  fecal  impaction,  492 
from  foreign  bodies,  492 
from  h>-pertrophy  of  O'Beirne's  sphinc- 
ter, 495,  503 
of  rectal  valves,  503 
from  intestinal  deviation,  493 
neoplasms,  499 
parasites,  499 
stricture.  498 
from  invagination,  502 
from  parah'tic  ileus,  502 
from  ptosis  of  sigmoid  flexure,  501 
from  rectal  diseases,  495,  503 

stenosis,  499 
from  splanchnoptosis,  500 
from  strictures,  493 
from  tumors,  493 
general  remarks.  488-490 
in  enteroptosis.  494 
in  enterospasm.  495 
in  paralytic  ileus,  495 
in  pericolitis,  404 
in  perisigmoiditis,  494 
in  splanchnoptosis,  494 
lesions  causing,  491 
location  of,  489 
s}-mptoms,  496 
treatment,  510 

non-operative.  510 
surgical.  511 
Occupation  in  entamebic  colitis.  327 
Qisophagostoma  brumpti,  436 
!  Oils  used  in  intestinal  irrigation,  477 
!  Old  age,  diarrhea  in.  121.  170 
I  Opsonic  index  in  tubercular  enteritis,  258 
\  Organotherapy  in  chronic  enteritis,  208 
Ox)-uriasis,  433 
diagnosis,  434 
symptoms.  433 
treatment,  434 
Oxyuris  vermicularis,  433 


Palp.\tion  in  diarrhea.  27,  28 
Pancreatic  bowel  disturbances,  differential 
diagnosis,  199 
diseases,  diarrhea  in,  60 


INDEX 


599 


Pancreatogenic  disorders  in  enteritis,  178 

Paradysenterj',  396 

Paralytic  ileus,  obstructive  diarrhea  from, 

495-  502 
Paramoeba  hominis,  326 
Paramcecium  coli,  446 
Parasitic  colitis,  422,  444.      See  also   Ilel- 
m'nitlik  colitis. 

diseases,    surgical    treatment,    542,    545, 

.556,574 

Patient,  preparation  of,  for  surgical  treat- 
ment, 543 

Pederasts,  gonorrheal  colitis  in,  458 

Pellagra,  diarrhea  in,  99,  158 
pathology,  100 
symptoms,  gg 
treatment,  loi 

Pemphigus  acutus,  diarrhea  in,  67 
vulgaris,  diarrhea  in,  67 

Peptonitic  reaction  in    tubercular   enteritis, 
258 

Percussion  in  diarrhea,  27 

Pericolic    membranes,   surgical    treatment, 

513 
Pericolitis,  diagnosis,  506 

obstructive  diarrhea  in,  494 
Perisigmoiditis,  diagnosis,  506 

obstructive  diarrhea  in,  494 
Peritoneal  tuberculosis,  diagnosis,  265 
irrigating  treatment,  279 
symptoms,  248 
Peritoneum,  involvement  of,  in  tubercular 

enteritis,  223,  237 
Peritonitis,  cUfferential  diagnosis,  198 

with  perforation  in  tubercular  enteritis, 

wathout  perforation  in  tubercular  enteri- 
tis, 251 
Perityphlitis  actinomycotica,  102 
Pertussis,  diarrhea  in,  75 
Pettyjohn's    stab-wound    appendicostomy, 

57i~573 
Phosphorus-poisoning,  diarrhea  in,  166 
Physaloptera  caucasica,  437 

mordens,  437 
Pin-worms,  433 

Pityriasis  rubra,  diarrhea  in,  67 
Plague,  diarrhea  in,  96 
Pneumonia,  diarrhea  in,  76 
Pork,  measly,  cysticerci  in,  424 

tapeworm,  423 
Positions  for  intestinal  irrigation,  481 
Postoperative  diarrhea,  519,  520 
diagnosis,  522 
etiology,  519-522 
pathology,  519-522 
symptoms,  522 
treatment,  523 
surgical,  524 
Postprandial     diarrhea,     138.       See     also 

Neurogenic  diarrhea. 
Potassium  iodid  and  mercurj*  in  syphilitic 

enteritis,  315 
Potato-poisoning,  diarrhea  in,  156 
solanin  in,  157 
symptoms,  157 


Preparation  of  patient  for  surgical   treat- 
ment, 543 
Procidentia  recti,  surgical  treatment,  518 
Proctectomy,  582 

inferior,  583 

superior,  583 
Proctitis,  diagnosis,  196 

gonorrheal,    458.      See    also    Gonorrheal 
colitis. 
Proctoscopic  examination  in  diarrhea,  43 
Proctoscopy,  genupectoral  posture  for,  44 
Prophylaxis  in  ptomain-poisoning,  161 

in  tubercular  enteritis,  267 
Protozoal  colitis,  444 

dysentery,  444 
Pseudodyscntery,  395 
Pscudodysenteric  diarrhea,  96 
Pseudo-enteritis,  183 
Pseudoleukemia,  diarrhea  in,  1 10 
Pseudomembranous  bacillary  colitis,  405 
Psilosis  hnguae  et  mucosa;  interna;,  93.    See 

also  Sprue. 
Psoas  abscess,  differentiation  from  hj-per- 

plastic  tubercular  enteritis,  265 
Psj'chic  ner\-ous  diarrhea,  139 
Ptomain-poisoning,  diagnosis,  159 

diarrhea  from,  150 

differential  diagnosis  of,  197 

differentiation  from  tubercular  enteritis, 
260 

prophylaxis.  161 

symptoms,  159 

treatment,  161 
Pucrj^eral  diarrhea  of  Bengal,  97 
Purpura,  diarrhea  in,  89 
Pus  in  feces,  39 


Quixix,  salts  of,  for  entamebic  colitis,  549 


Racial  predisposition  in  entamebic  colitis, 
327 

Rectal  cancers,  treatment,  surgical,  512 
complications  in  entamebic  colitis.  363 
diseases,  obstructive  diarrhea  from,  495, 

examination,  Sims'  posture  for,  25 
polypi,  treatment,  surgical,  518 
stenosis,  obstructive  diarrhea  from,  499 
strictures  in  entamebic  colitis,  364 
tube  for  colonic  inflation,  31 
ulcers  in  entamebic  colitis,  364 
valves,  enlarged,  diagnosis.  508 

hyT^ertrophied,  surgical  treatment,  516 
obstructive  diarrhea  from.  503 
Rectocele,  diagnosis.  506 
Rectocolonic  transillumination.  42 
Rectum,  congenital  deformities  of.  surgical 
treatment.  511 
digital    examination    of,    in     tubercular 

enteritis.  311 
invoKement  of,  in  tubercular  enteritis,  239 
Reflex  disturbances,  diarrhea  in,  122 

in  neurogenic  diarrhea,  142 
Relapsing  fever,  diarrhea  in,  81 


6oo 


INDEX 


Remedies,     symptomatic,     for     tubercular 
enteritis,  276 

Resection    and    amputation    in    entamebic 
colitis,  3QI 
of  bowel  in  tubercular  enteritis,  286 

Rest  for  tubercular  enteritis,  268 
in  bed  for  acute  enteritis,  201 

Rhabditis  intestinalis,  436 

Rontgen  ray  in  diagnosis  of  diarrhea,  48 
bismuth  subcarbonate  for,  52 

Rosenberg  dry  treatment  for  chronic  enteri- 
tis, 208 

Round  worms,  427,  431 


Salvarsan  in  syphilitic  enteritis,  314 
Sausage-poisoning,  toxemia  from,  152 
Scarlet  fever,  diarrhea  in,  74 
Schaudinn's  demonstration  of  pathogenicity 

of  Entamreba  histol3'tica,  325 
Schistosoma  haematobium,  438 

japonica,  437 

mansoni,  438 
Schistosomiasis,  437 

etiology,  437 

intestinal,  440 
treatment,  441 

pathology,  438 

prognosis,  441 

symptoms,  440 

treatment,  441 

urinary,  441 
Schizogony,  reproduction  of  entamebae  by, 

339 
Sclerema  neonatorum,  diarrhea  in,  67 
Scurvy,  diarrhea  in,  113 
Sepsis,  diarrhea  in,  89 

treatment,  8q 
Septodera  intestinalis,  436 
Serum  treatment  of  bacillary  colitis,  416 
mortality  after,  418 
of  tubercular  enteritis,  282 
Sex  in  entamebic  colitis,  327 
in  tubercular  enteritis,  214 
Shell-fish  poisoning,  diarrhea  in,  154 
Short-circuiting    of    bowel    in    tubercular 

enteritis,  286 
Sigmoid,  chronic  invagination  of,  surgical 
treatment,  513 
involvement  of,   in   tubercular   enter- 
itis, 239 
ptosis  of,  obstructive  diarrhea  from,  501 
Sigmoiditis,  diagnosis,  195 
Sigmoidoscopic    examination    in    diarrhea, 

.43 
Sims'  posture  for  rectal  examination,  25 
Sitophobia,  diarrhea  in,  117 
Skin  atTections  in  entamebic  colitis,  362 
diarrhea  in,  67 
treatment,  68 
Solanin  in  potato-poisoning,  157 
Soothing  remedies  for  tubercular  enteritis, 

273-275 
Sphincter  ani,  hypertro])hy,  diagnosis,  509 
preservation    of,    in    celioproctectomy, 
585 


Spirochacta  pallida   in   syphilitic   enteroco- 
litis, 446 
diagnosis,  308 
Splanchnoptosis,  diagnosis,  507 

obstructive  diarrhea  in,  494,  500 

surgical  treatment,  515 
Sprue,  93 

diagnosis,  93 

etiology,  93 

symptoms,  93 
Stab-wound   appendicostomj',  Pettyjohn's, 

571-573 
Statistics  of  ileocolectomy,  289 
of  intestinal  exclusion,  290 
of    operative    treatment    of    tubercular 
enteritis,  290 
Steatorrhea  in  enteritis,  188 
Stimuli  producing  diarrhea,  18 
Stomach  bucket,  Einhorn's,  32 

carcinoma  of,  gastrogenic  diarrhea  from, 

124 
contents,  examination  of,  in  diarrhea,  31 

removal  of,  32 
inflation  for  diagnosis  of  diarrhea,  29 
involvement  of,  in  tubercular  enteritis,  238 
Stomach-tube  for  gastric  diagnosis,  S3 
Stools,  blood  in,  38 
examination  of,  36-40 
in  entamebic  colitis,  371 
in  syphilitic  enteritis,  309 
fermenting,  in  enteritis,  196 
green,  in  enteritis,  107 
in  diarrhea  alba,  94 
mucus  in,  38 

ocher-colored,  in  enteritis,  197 
pus  in,  39 

putrefying,  in  enteritis,  107 
Streptothrix  actinomyces,  loi 
Stricture  of  intestine,  patholog\',  299-301 
Strongyloides  intestinalis,  92,  436 

stercoralis,  436 
Strongyloidosis,  436 
diagnosis,  436 
symptoms,  436 
treatment,  436 
Strongj'lus  gibsoni,  437 
StjTJtic  remedies  in  tubercular  enteritis,  277 
Succus  entericus,  unbalanced,  132 
Sunstroke,  diarrhea  from,  120 
Suprarenal  diseases,  diarrhea  in,  64 
Surgical  diarrhea,  488,  406,  504,  510.     See 
also  Obslriictivc  diarrhea. 
treatment,  closure  of  opening  after,  550 
general  remarks  on,  546 
historic  note  on,  545 
of  diarrheal  diseases,  542,  545,  556,  574 
of  inllammatory  diseases,  542,  545,  556, 

574     _ 
of  parasitic  diseases,  542,  545,  556,  574 
table  of  cases,  545 
Sutika,  diarrhea  in,  97 
Sj'philis,  anorectal,  jxithology,  302 

intestinal,  294,  304,  313.    See  also  Syph- 
ilitic enteritis. 
Syphilitic  colitis,  294,  304,  313.     See  also 
Syphilitic  enteritis. 


INDEX 


6oi 


Syphilitic  enteritis,  294,  304,  313 

and    tubercular    enteritis,  dilTcrcntial 

diagnosis,  308 
appendicostomy  for,  319 
blood  examination  in,  310 
cancer  caused  by,  308 
cccostomy  for,  319 
colic  in,  305 
diagnosis  of,  307 

Spirochaeta  pallida  in,  308 
test-meals  in,  310 
Wassermann  reaction  in,  308 
differentiation  from  tubercular  enteri- 
tis, 259 
enterocecostomy  for,  319 
enterospasm  in,  306 
etiology,  296 

examination    of    intestine    in,    macro- 
scopic, 310 
of  stools  in,  309 
flatus  in,  306 

intestinal  exclusion  for,  319 
iodipin  in,  316 
mclena  in,  309 

mercurial  preparations  in,  317 
mercury  and  potassium  ioclid  in,  315 
neosalvarsan  in,  315 
pathology,  297,  302 
proctoscopic  examination  in,  310 
prognosis,  311 
salvarsan  in,  314 

sigmoidoscopic  examination  in,  310 
Spirocha?ta  pallida  in,  446 
symptoms,  304 
treatment,  313 
medicinal,  313 
mercurial,  by  injection,  317 
surgical,  318 
tuberculosis  caused  by,  308 
urinalysis  in,  311,  312 
enterocolitis,    294,    304,    313.      See   also 

Sypliilitic  entcrilis. 
intestinal  ulcers,  298-301 
Syringe,  Davidson's,  473 
fountain,  475 
hard-rubber  enema,  471 
Jamison's  seat,  479 
metal  piston  enema,  472 


Tabes  dorsalis,  neurogenic  diarrhea  in,  143 
Table  of  characteristics  of  Bacillus  dysen- 
teria;,  398 

illustrating    site    of    rupture    in    hepatic 
abscess,  366 
Taenia  lata,  424 

nana,  425 

saginata,  424 

solium,  423 
Tapeworm,  423 

beef,  424 

fish,  424 

pork,  423 
Technic  for  intestinal  irrigation,  480 

for  passing  colon-tube,  Gant's,  486 

of  cecostomj',  554 


Tenesmus,  relief  of,  in  entamebic  colitis,  379 
Teniasis,  diagnosis,  425 
symptoms,  425 
treatment,  426 
Test-meals  in  diagnosis  of  syphilitic  enteri- 
tis, 310 
in  diarrhea,  32 
Thread-worms,  433 
Thrombosis,    mesenteric,    526.      See    also 

Mesenteric  emboli.sm. 
Through-and-through  irrigation,  471 
following  ajipendicostomy,  552 

cecostomj-,  552 
in    surgical    treatment    of    entamebic 

colitis,  390 
in  tubercular  enteritis,  287,  288 
ThjToid  diseases,  diarrhea  in,  56 
Thyroidism,  myxorrhea  coli  in,  463 
Tonic  remedies  in  tuljercular  enteritis,  272 
Tonics  in  entamebic  colitis,  3S0 
Topical  api^lications  in  bacillary  colitis,  419 
in  entamebic  colitis,  3S3 
in  tul)ercular  enteritis,  280 
Toxemia  from  i)otulism,  152 
from  deca\^cd  meat,  152 
from  diseased  meat,  151 
from  sausage-poisoning,  152 
Toxic  diarrhea,  150,  163 
Toxins,  absorption  of,  in  bacillarj'  colitis, 

401. 
Transillumination,  rectocolonic,  42 
Treatment,   electric,    for   chronic   enteritis, 
205 
irrigating,  of  glandular  tuberculosis,  279 
of  peritoneal  tuberculosis,  279 
of  tubercular  enteritis,  278 
deep  ulcerative,  278 
fibrosclerotic,  279 
hyper]>lastic,  279 
superficial  ulcerative,  278 
medical,  of  chronic  enteritis,  205 
of  diarrhea,  19,  20 
of  syi)hilitic  enteritis.  313 
of  tubercular  enteritis,  271 
mercurial,    by    injection,    in    sj^ihilitic 

enteritis,  317 
non-operative,    of   obstructive    diarrhea, 

of  acute  enteritis,  200 
of  ascariasis,  433 

of  bacillary  colitis,  irrigating,  418 
local,  418 
medical,  414 
prophylactic,  413 
serum,  416 
supportive,  414 
surgical,  420 
vaccine,  416 
of  balantidic  colitis,  457 
of  cholera,  83 
of  diarrhea  alba,  95 
cathartica,  116 
compensatory.  173 
coprostatic,  105 
enterogenic,  135 
from  chilling,  119 


602 


INDEX 


Treatment  of  diarrhea  from  cold  beverages, 
1 20 
gastrogenic,  128 
in  acute  infectious  diseases,  76 
in  alcoholism,  m 
in  alkali-poisoning,  168 
in  bone  diseases,  68 
in  chronic  nephritis.  63 
in  diabetes  meUitus.  63 
in  eye  diseases.  54 
in  female  genital  diseases,  65 
in  Uver  diseases.  60 
in  male  genital  diseases.  66 
in  mercurial  poisoning.  165 
in  mouth  diseases,  55 
in  nasopharATigeal  diseases,  56 
in  obesit\\  107 
in  pancreatic  diseases,  61 
in  relapsing  fever.  Si 
in  sepsis.  89 
in  skin  diseases.  68 
in  suprarenal  diseases.  64 
in  th\Toid  diseases.  57 
of  entamebic  colitis.  376 

dietetic,  377 

Hanes'  coal-oil,  387 

Jelks'  formalin-boric  solution  in.  387 

local.  383 

irrigants  in,  386 

medical.  379 

prophylactic,  376 

supportive.  377 

surgical,  389-391 
by  through-and-through  irrigation, 

390  .    ■ 

of  gonorrheal  colitis.  459 
of  hepatic  abscess,  392 

surgical.  392 
of  intestinal  amj^loidosis,  71 
mxnasis.  90 
schistosomiasis.  441 
of  mesenteric  embolism.  528 
of  m\-xorrhea  coli.  466 
of  night-sweats  in  tubercular  enteritis,  278 
of  obstructive  diarrhea.  510.  511 
of  oxATiriasis,  434 
of  peUagra.  loi 
of  postoperative  diarrhea.  523 

surgical.  524 
of  ptomain-poisoning,  161 
of  schistosomiasis.  441 
of  sporadic  cholera.  85 
of  strongj-loidosis.  436 
of  s\-philitic  enteritis,  312 
of  teniasis.  426 
of  trichiniasis.  430 
of  trichuriasis,  436 
of  tropical  diarrhea,  94 
of  tubercular  enteritis,  irrigating,  280 

surgical,  285 
of  imcinariasis.  430 
of  urinarj-  diarrhea,  66 
of  winter  cholera,  88 
of  }-ellow  fever.  81 

operative,  of  intestinal  stenosis,  statistics 
of,  291 


Treatment,   operative,   of    tubercular    en- 
teritis,  author's   conclusions  in, 
291-293 
statistics  of,  290 
routine,  in  tubercular  enteritis,  266 
serum,  of  tubercular  enteritis,  282 
surgical,  general  remarks  on,  542 
of  anal  fissure,  517 

of  chronic  invagination  of  sigmoid,  513 
of  coccygeal  deformity,  51S 
of  coloptosis,  515 

of  congenital  deformities  of  rectimi,  511 
of  diarrheal  dbeases,  542.  545.  556,  574 
of  diverticula  of  colon,  515 
of  enteroptosis,  515 
of  enterospasm,  516 
of  fecal  impaction,  513 
of  fibrinomembranous  partitions,  511 
of  foreign  bodies.  512 
of  hemorrhoids.  517 
of  h>-pertrophy  of  anal  sphincter,  517 
of  O'Beime's  sphincter,  516 
of  rectal  valves.  516 
of  imperforate  anus.  511 
of  inflammatory-  diseases,  542,  545,  556, 

of  intestinal  adhesions,  513 
obstruction  from  parasites,  516 
strictures.  512 
tumors.  512 
of  mj-xorrhea  coli.  468 
of  parasitic  diseases.  542.  545.  556,  574 
of  pericoUc  membranes.  513 
of  procidentia  recti.  518 
of  rectal  cancers.  512 

poh-pi.  518 
of  splanchnoptosis.  515 
of  sj-phihtic  enteritis.  318 
of  tubercular  enteritis,  local  anesthesia 

in,  285 
of  voh"ulus.  513 
preparation  of  patient  for,  543 
Trematodes.  437 
TrichineUa  spiralis.  430 
Trichiniasis,  430 
sxTnptoms,  430 
treatment.  430 
Trichocephaliasis.  435.    See  also  Trichuria- 
sis. 
Trichocephalus  dispar,  435 
hominis.  435 
trichiuris.  435 
Trichomonas  hominis,  444 
Trichostrong\-lus.  tjpes  of,  437 
Trichuriasis,  435 
diagnosis,  436 
sj-mptoms,  436 
treatment,  436 
Trichuris  trichiura,  435,  436 
Triodontophorus  diminutus.  437 
Tropical   abscess.   364.      See   also   Hepatic 

abscess. 
True  dysenten,-.  395 

Tubercular  colitis.  211,  210,  240.  255,  266, 
285.    See  also  Tubercular  enteritis. 
enteritis,  211,  219,  240,  255,  266,  285 


INDEX 


603 


Tubercular  enteritis,  abscesses  in,  252 
adhesions  of  bowel  in,  252 
advanced,  nuxed  infection  in,  245 
age  of  occurrence,  214 
albuminuria  in,  257 
and  ischiorectal  abscess,  245 
and     s>ijhilitic     enteritis,     differential 

diagnosis,  308 
antiseptic  remedies  for,  273-275 
appendicostomy  in,  288 
bilateral  exclusion  of  bowel  in,  286 
blood  analysis  in,  258 
carcinoma  complicating,  254 
cecal  involvement  in,  212 
cecostomy  in,  288 
change  of  occupation  in,  269 
classification,  219 
colostomy  for,  288 
complications,  249 
constipation  in,  243 
controlling  fever  in,  277 
deep   ulcerative,   irrigating   treatment, 
278 
patholog)',  223 
diarrhea  in,  242,  255 
diazo-reaction  in,  258 
diet  in,  270 
differentiation  from  duodenal  ulcer,  259 

from  dysentery,  260 

from  dyspeptic  enteritis,  260 

from  gastric  ulcers,  259 

from  ptomain-poisoning,  260 

from  s>-philitic  enteritis,  259 

from  t>'phoid  fever,  259 
digital  examination  of  rectum  in,  311 
duodenal  involvement,  212 
etiology,  213 

exclusion  of  bowel  in,  bilateral,  286 
unfavorable  features,  287 
unilateral,  286 
exercise  in,  268 
fibrosclerotic,  234,  248 

irrigating  treatment,  279 
fistulse  in,  252 
foods  permitted  in,  270 

prohibited  in,  271 
frequency  in  general  tuberculosis,  219 
fresh  air  for,  268 
gas  distention  in,  245 
general  diagnosis,  255 
glandular,  235 

sj'mptoms,  248 — — 

hyjjerplastic,  227 

age  in,  227 

and  cancer,  differential  diagnosis,  263 

appearance  of  intestine  in,  231 

bovine  bacillus  in,  229 

diagnosis,  260 

differential  diagnosis,  262 

differentiation  from  appendicitis,  264 
from  psoas  abascess,  265 

frequency  of  occurrence,  228 

history,  227 

involvement  of  appendix,  233 
of  glands,  234 
of  muscular  tunic,  232 


Tubercular  enteritis,  hyperplastic  involve- 
ment of  peritoneal  coat,  233 
of  submucosa,  232 
of  subserosa,  233 

irrigating  treatment,  279 

mucous  membrane  in,  231 

polj'poid  growths  in,  232 

sjTnptoms,  246 
ileac  involvement  in,  212 
improving  general  health  in,  267 

mental  condition  in,  267 
in  miUary  tuberculosis,  246 
in  tuberculosis  of  other  organs,  table  of, 

216 
infrequency  in  general  tuberculosis,  229 
involvement  of  a[>pendLx,  238 

of  colon,  239 

of  peritoneum,  223,  237 
diagnosis,  265 
sjTnptoms,  248 

of  rectum,  239 

of  sigmoid  flexure,  239 

of  stomach,  238 
irrigating  treatment,  278 
Jejunal  involvement  in,  212 
kinks  of  bowel  in.  2^2 
miliar}'  tuberculosis  in,  253 
mode  of  infection.  214 
obstipation  in,  243 

operative   treatment,  author's  conclu- 
sions on,  291-293 
opsonic  index  in,  258 
pain  and  tenderness  in,  243 
peptonitic  reaction  in,  258 
peritonitis  with  i)erforation  in,  251 

without  perforation  in,  251 
predisposing  causes,  213 
primary,  217 

table  of,  217 
proper  clothing  in,  269 
prophylaxis  in,  267 
relative  frequency  of,  211 
resection  of  bowel  in,  286 
resembling  actinomycosis,  259 

amyloid  degeneration,  259 

appendicitis.  245 
rest  in  bed  for.  26S 
routine  treatment,  266 
secondarj',  217 
sec}uel3e,  249 
serum  treatment,  282 
sex  in,  214 

short-circuiting  of  bowel  in.  286 
soothing  remedies  for.  273-275 
statistics  of  operative  treatment,  290 
stricture,  249-251 
styptic  remedies  in.  277 
superficial  ulcerative,  irrigating  treat- 
ment, 278 
sjTnptomatic  remedies  for,  276 
through-and-through  irrigauon  in,  287, 

288 
tonic  remedies  for,  272 
toi)ical  applications  in,  280 
treatment,  medical,  271 

surgical,  285 


6o4 


INDEX 


Tubercular   enteritis,   treatment,   surgical, 
local  anesthesia  in,  2S5 
irrigants  used,  280 
of  night-sweats  in,  278 
tuberculin  reaction  in,  257 
twists  of  bowel  in,  252 
ulcerative,  diagnosis,  256 
sj-rnptoms,  240 
ulcer  of  intestine,  characteristics,  222 
Tuberculin  reaction  in  tubercular  enteritis, 

257 
Tuberculosis,    enteroperitoneal,    diagnosis, 
256 
sjonptoms,  241 
general,  frequency  in  tubercular  enteritis, 
219 
infrequency  of  tubercular  enteritis  in, 
229 
glandular,  irrigating  treatment,  279 
intestinal,  211,  219,  240,  255,  266,  285. 

See  also  Tiiberciilar  enteritis. 
mihary,  in  tubercular  enteritis,  246,  253 
of  other  organs,  tubercular  enteritis  in, 

table  of,  216 
peritoneal,  diagnosis,  265 
irrigating  treatment,  279 
sjTnptoms,  248 
syphiUtic  enteritis  in,  308 
Timiors   of  intestine,  malignant,  differen- 
tial diagnosis,  199 
benign,  differential  diagnosis,  199 
TjTjhlitis,  diagnosis,  195 
TjTjhoid  fever,  differential  diagnosis  of,  197 
diff'erentiation  from  tubercular  enteri- 
tis, 259 
resemblance  to  hemorrhagic  enteritis, 
182 
Tjphus  fever,  diarrhea  in,  79,  96 
Tyrotoxicon  in  cheese-poisoning,  154 


Ulcers,  uremic,  62 
Uncinariasis,  427 
diagnosis,  430 
pathology,  429 


Uncinariasis,  prognosis,  430 

symptoms,  429 

treatment,  430 
Unsegmented  worms,  427 
Uremic  ulcers,  62 

Urinalysis  in  syphilitic  enteritis,  311 
Urinary  changes  in  entamebic  colitis,  363 

diarrhea,  66 
treatment,  66 

scliistosomiasis,  441 
Urine,  examination  of,  in  diarrhea,  41 
Urticaria ,  diarrhea  in,  67 


Vaccixe  treatment  for  bacillarj'  colitis,  416 

Vaccines  for  chronic  enteritis,  208 

Vaginal  proctectomy,  584 

Vahlkampfia,  333 

Varicella,  diarrhea  in,  74 

Variola,  diarrhea  in,  75 

Vibration  for  chronic  enteritis,  204 

Volvulus,  surgical  treatment,  513 


WASSERiiAxx  reaction  in  diagnosis  of  sj'ph- 

ihtic  enteritis,  307 
WTiip- worms,  435 
Worms,  flat,  423 

fluke-,_  43  7 

lumbricoid,  431 

pin-,  433 

round,  431 

tape-,  423 

thread-,  433 

whip-,  435 


X-RAY  in  diagnosis  of  diarrhea. 
Rontgen  ray. 


See  also 


Yellow  fever,  diagnosis 
diarrhea  in,  79 
prognosis.  So 
treatment,  81 


80 


SAUNDERS'  BOOKS 


on 


Skin,  Genito  -  Urinary , 

Chemistry,  Eye,  Ear,  Nose, 

and  Throat,  and  Dental 

W.  B.  SAUNDERS   COMPANY 

WEST  WASHINGTON  SQUARE  PHILADELPHIA 

9.  HENRIETTA  STREET.  COVENT  GARDEN,  LONDON 

D&vis*   Accessory  Sinuses 

Development  and  Anatomy  of  the  Nasal  Accessory  Sinuses  in 
Man.  By  Warren  B.  Davis,  M.  D.,  Corinna  Borden  Keen  Research 
Fellow  of  the  Jefferson  Medical  College,  Philadelphia.  Octavo  of  172 
pages,  with  57  original  illustrations.  Cloth,  $3.50  net. 

ORIGINAL  DISSECTIONS 

This  book  is  based  on  the  study  of  two  hundred  and  ninety  lateral  nasal  walls, 
presenting  the  anatomy  and  physiology  of  the  nasal  accessory  sinuses  from  the 
sixtieth  day  of  fetal  life  to  advanced  >natiirity.  It  represents  the  oriqinal  research 
work  and  personal  dissections  of  Dr.  Davis  at  the  Daniel  Baugh  Institute  of 
Anatomy  of  Philadelphia  and  at  the  Friedrichshain  Krankenhaus  of  Berlin.  It 
was  necessary  for  Dr,  Davis  to  develop  a  new  technic  by  which  the  accessory 
sinus  areas  could  be  removed  <?«  masse  at  the  time  of  postmortem  examinations, 
and  still  permit  of  reconstruction  of  the  face  without  marked  disfigurement. 
Ninety-six  cases  in  this  series  were  thus  obtained.  The  tables  of  averages,  giving 
you  the  age,  size  of  ostia,  origin,  thickness  of  septum,  and  anterior  and  posterior 
walls,  vertical,  lateral,  and  posterior  diameters,  and  relation  to  the  nasal  floor, 
form  an  extremely  valuable  feature. 


SAUXDERS'    BOOKS    OX 


StelwagonV 
Diseases  of  the  Skin 


A  Treatise  on  Diseases  of  the  Skin.     By  Hexrv  W.  Stelwagon, 

M.  D.,  Ph.  D.,  Professor   of  Dermatology  in    the   Jefferson    Medical 

College,  Philadelphia.     Octavo  of  1250  pages,  with  331   text-cuts  and 

33  plates.  Cloth.  $6.00  net;  Half  Morocco,  $7.50  net. 

THE  NEW    7th     EDITION 

There  are  two  features  in  Dr.  Stehvagon's  work  that  stand  out  above  all  the 
others  :  The  special  emphasis  given  the  two  practical  phases  of  the  subject — 
dtagjtosis  and  treatment ;  and  the  wealth  of  illustrations.  These  latter  are  of  real 
value.  They  teach  you  diagnosis  as  no  description  can.  Many  of  these  illustra- 
tions are  in  colors. 

Over  75  pages  of  the  work  are  devoted  to  syphilis,  giving  you  the  Wassermann 
test,  the  salvarsan  ("606")  treatment,  and  all  the  newest  advances.  Pellagra, 
tropical  affections,  hookworm  disease.  Oriental  sore,  ringworm,  impetigo  contagiosa 
— all  those  diseases  being  so  widely  discussed  to-day. 

George  T.  Elliot,  M.  D.,   Professor  of  Dermatology,  Cornell  University. 

"  It  is  a  book  that  I  recommend  to  my  class  at  Cornell,  because  for  conservative  judgment, 
for  accurate  observation,  and  for  a  thorough  appreciation  of  the  essential  position  of  derma- 
tology, I  think  it  holds  first  place." 


SchambergCs  Diseases  qf  the  Skin 
and  Eruptive  Fevers 


Diseases  of  the  5kin  and  the  Eruptive  Fevers.  By  J.^y  F.  Schamberg, 
M.  D.,  Professor  of  Dermatology  and  the  Infectious  Eruptive  Diseases,  Philadel- 
phia Polyclinic.     Octavo  of  573  pages,  illustrated.     Cloth,  $3. 00  net. 

THE  NEW  i2d)  EDITION 

"  The  acute  eruptive  fevers  constitute  a  valuable  contribution,  the  statements  made 
emanating  from  one  who  has  studied  these  diseases  in  a  practical  and  thorough  manner  from 
the  standpoint  of  cutaneous  medicine.  .  .  ,  The  views  expressed  on  all  topics  are  con- 
ser\'ative,  safe  to  follow,  and  practical,  and  are  well  abreast  of  the  knowledge  of  the  present 
time,  both  as  to  general  and  special  pathology,  etiology,  and  treatment." — American  Journal 
•/  Medical  Sciences. 


GEN  I  TO-  URIXAR  Y  DISEASES 


Norris* 
Gonorrhea  in  Women 

Gonorrhea  in  Women.  By  Charles  C.  Norris,  M.  D.,  Instructor 
in  Gynecology,  University  of  Pennsylvania,  with  an  Introduction  by 
John  G.  Clark,  M.  D.,  Professor  of  Gynecology,  University  of  Penn- 
sylvania.    Large  octavo  of  520  pages,  illustrated.  Cloth,  $6.00  net. 

A  CLASSIC 

Dr.  Norris  here  presents  a  work  that  is  destined  to  take  high  place  among 
publications  on  this  subject.  He  has  done  his  work  thoroughly.  He  has  searched 
the  important  literature  very  carefully,  over  2300  references  being  utilized. 
This,  coupled  with  Dr.  Norris'  long  experience,  gives  his  work  the  stamp  of 
authority.  The  chapter  on  serum  and  vaccine  therapy  and  organotherapy  is 
particularly  valuable  because  it  expresses  the  newest  advances.  Every  phase  of 
the  subject  is  considered. 

Pennsylvania  Medical  Journal 

"  Dr.  Norris  has  succeeded  in  presenting  most  comprehensively  the  present  knowledge  of 
gonorrhea  in  women  in  its  many  phases.  The  present  status  of  serum  and  vaccine  therapy  is 
given  in  detail." 


Sharp's 

OphthalmoIog(y  for   Veterinarians 

ophthalmology  for  Veterinarians.  By  Walter  N.  Sharp,  M.  D., 
Professor  of  Ophthalmology  in  the  Indiana  Veterinary  College.  i2mo 
of  210  pages,  illustrated.     Cloth,  ^2.00  net. 

ILLUSTRATED 

This  new  work  covers  a  much  neglected  but  important  field  of  veterinary 
practice.  Dr.  Sharp  has  presented  his  subject  in  a  concise,  crisp  way,  so  that 
you  can  pick  up  this  book  and  get  to  "the  point"  quickly.  He  first  gives  you  the 
anatomy  of  the  eye,  then  examination,  followed  by  the  various  diseases,  including 
injuries,  parasites,  errors  of  refraction,  and  medicines. 

Dr.  George  H.  Glover,  Agricultural  Experiment  Station,  Fort  Collins. 
"  The  best  book  on  the  subject  on  the  market." 


SAUNDERS'    BOOKS    ON 


Barnhill   and  Wales* 
Modern   Otology 

A  Text=Book  of  Modern  Otology.  By  John  F.  Barnhill,  M.  D,, 
Professor  of  Otologv^  Laryngology,  and  Rhinology,  and  Earnest 
DE  W.  Wales,  M.  D.,  Associate  Professor  of  Otology,  Laryngolog}', 
and  Rhinology,  Indiana  University''  School  of  Medicine,  Indianapolis. 
Octavo  of  598  pages,  with  314  original  illustrations.  Cloth,  $3.50  net; 
Half  Morocco,  37.00  net. 

THE  NEW  (2d)  EDITION 

The  authors,  in  writing  this  work,  kept  ever  in  mind  the  needs  of  the 
physician  engaged,  in  general  practice.  It  represents  the  results  of  personal 
experience  as  practitioners  and  teachers,  influenced  by  the  instruction  given  by 
such  authorities  as  Sheppard,  Dundas  Grant,  Percy  Jakins,  Jansen,  and  Alt. 
Much  space  is  devoted  to  prophylaxis,  diagnosis,  and  treatment,  both  medical 
and  surgical.  There  is  a  special  chapter  on  the  bacteriology  of  ear  affections — 
a  feature  not  to  be  found  in  any  other  work  on  otology.  Great  pains  have  been 
taken  with  the  illustrations,  in  order  to  have  them  as  practical  and  as  helpful  as 
possible,  and  at  the  same  time  highly  artistic.  A  large  number  represent  the 
best  work  of  Mr.  H.  F.  Aitken. 


PERSONAL    AND    PRESS    OPINIONS 


Frank  Allport.  M.  D. 

Professor  of  Otology,  Northwestern  University,  Chicago. 

"  I  regard  it  as  one  of  the  best  books  in  the  English  language  on  this  subject.  The 
pictures  are  especially  good,  particularly  as  they  are  practically  all  original  and  not  th';  old 
reproduced  pictures  so  frequently  seen." 

C.  C.  Stephenson.  M.  D. 

Professor  of  Ophthalmology  aud  Otology.  College  of  Physicians  and  Surgeons,  Little  Rock 
Arkansas. 

"To  my  mind  there  is  no  work  on  modern  otology  that  can  for  a  moment  compare  with 
•  Barnhill  and  Wales."  " 

Journal  American   Medical  Association 

"  Its  teaching  is  sound  throughout  and  up  to  date.  The  strongest  chapters  are  those  on 
suppuration  of  the  middle  ear  and  the  mastoid  cells,  and  the  intracranial  complications  of  eai 
disease." 


DISEASES   OF   THE  EYE. 


DeSchweinitz*s 
Diseases  of  the  Eye 

Seventh  Edition 


Diseases  of  the  Eye:  A  Handbook  of  Ophthalmic  Practice. 
By  G.  E.  deSchvveinitz,  M.D.,  Professor  of  Ophthalmology  in  the  Uni- 
versity ot  Pennsylvania,  Philadelphia,  etc.  Handsome  octavo  of  979 
pages,  360  text-illustrations,  and  7  chromo-lithographic  plates.  Cloth, 
$5.00  net;  Sheep  or  Half  Morocco,  ;^6.50  net. 

WITH  360  TEXT-ILLUSTRATIONS  AND  7  COLORED  PLATES 
THE  STANDARD  AUTHORITY 

Dr,  deSchweinitz's  book  has  long  been  recognized  as  a  standard  authority 
upon  eye  diseases,  the  reputation  of  its  author  for  accuracy  of  statement  placing  it 
far  in  the  front  of  works  on  this  subject.  For  this  edition  Dr.  deSchweinitz  has 
subjected  his  book  to  a  most  thorough  revision.  Many  new  subjects  have  been 
added,  a  number  in  the  former  edition  have  been  rewritten,  and  throughout  the 
book  reference  has  been  made  to  vaccine  and  serum  therapy,  to  the  relation  of 
tuberculosis  to  ocular  disease,  and  to  the  value  of  tuberculin  as  a  diagnostic  and 
therapeutic  agent. 

The  text  is  fully  illustrated  with  black  and  white  cuts  and  colored  plates,  and 
in  every  way  the  book  maintains  its  reputation  as  an  authority  upon  the  eye. 


PERSONAL  AND   PRESS  OPINIONS 


Samuel  Theobald,  M.D., 

Clinical  Professor  of  Ophthalmology,  Johns  Hopkins  University,  Baltimore. 
"  It  is  a  work  that  I  have  held  in  high  esteem,  and  is  one  of  the  two  or  three  books  upon 
the  eye  which  I  have  been  in  the  habit  of  recommending  to  my  students  in  the  Johns  Hopkins 
Medical  School," 

University  oi  Pennsylvania  Medical  Bulletin 

"  Upon  reading  through  the  contents  of  this  book  we  are  impressed  by  tne  remarkable 
fulness  with  which  it  reflects  the  notable  contributions  recently  made  to  ophthilmic  literature. 
No  important  subject  within  its  province  has  been  neglected." 

Johns  Hopkins  Hospital  Bulletin 

•  No  smgle  chapter  can  be  selected  as  the  best.  They  are  all  the  product  of  a  finished 
authorship  and  the  work  of  an  exceptional  ophthalmologist.  The  work  is  certainly  one  of  the 
best  on  ophthalmology  extant,  and  probably  the  best  by  an  American  author." 


SAUNDERS'  BOOKS   ON 


GET  i^  •  THE  NEW 

THE    BEST  s\  lH  6  T  1  C  Sk  U  STANDARD 

Illustrated  Dictionary 

New  (7th)  Edition— 5000  Sold  in  Two  Months 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  Veterinary  Science,  Nursing,  and  kindred 
branches ;  with  over  lOO  new  and  elaborate  tables  and  many  illustra- 
tions. By  W.  A.  Newman  Borland,  AI.D.,  Editor  of  "  The  American 
Pocket  Medical  Dictionary."  Large  octavo,  with  1 107  pages,  bound  in 
full  flexible  leather.     Price,  $4.50  net ;  with  thumb  index,  $5.00  net. 

KEY  TO  CAPITALIZATION  AND  PRONUNCIATION— ALL  THE  NEW  WORDS 

This  dictionary  is  the  "new  standard."  It  defines  hundreds  of  the  newest 
terms  not  defined  in  any  other  dictionary — bar  none.  These  terms  are  hve, 
active  words,  taken  right  from  modern  medical  hterature. 

Howard  A.  Kelly,  M.  D., 

Professor  of  Gynecologic  Surgery,  Johns  Hopkins  University,  Baltimore 

"Dr.  Borland's  Dictionary  is  admirable.     It  is  so  well  gotten  up  and  of  such  convenient 
size.     No  errors  have  been  found  in  my  use  of  it." 


Theobald's  Prevalent  Eye  Diseases 


Prevalent  Diseases  of  the  Eye.  By  Samuel  Theobald,  M.  D., 
Clinical  Professor  of  Ophthalmology  and  Otology,  Johns  Hopkins 
University.  Octavo  of  5 50 pages,  with  2 19  text-cuts  and  several  colored 
plates.     Cloth,  S4.50  net ;  Half  Morocco,  ;^6.oo  net. 

THE    PRACTITIONER'S    OPHTHALMOLOGY 

With  few  exceptions  all  the  works  on  diseases  of  the  eye,  although  written 
ostensiblv  for  the  general  practitioner,  are  in  reality  adapted  only  to  the  specialist ; 
but  Dr.  Theobald  in  his  book  has  described  very  clearly  and  in  detail  those  condi- 
tions, the  diagnosis  and  treatment  of  which  come  within  the  province  of  the  general 
practitioner.  The  therapeutic  suggestions  are  concise,  unequivocal,  and  specific. 
It  is  the  one  work  on  the  Eye  written  particularly  for  the  general  practitioner. 

Charles  A.  Oliver,  M.D.. 

Clinical  Professor  of  Ophthalmology,   Woman's  Medical  College  of  Pennsylvania. 

"  I  feel  I  can  conscientiously  recommend  it,  not  only  to  ihe  general  physician  and  medical 
student,  for  v^fhom  it  is  primarily  written,  but  also  to  the  experienced  ophthalmologist.  MosJ 
surely  Dr.  Theobald  has  accomplished  his  purpose." 


DISEASES   OF   THE  EYE. 


Haab  and  DeSchweinitz*s 
External  Diseases  qf  the  Eye 


Atlas  and  Epitome  of  External  Diseases  of  the  Eye.     By  Dr.  O. 

Haab,  of  Zurich.  Edited,  with  addition.s,  by  G.  E.  deSchweinitz, 
M.  D.,  Professor  of  Ophthalmology,  University  of  Pennsylvania.  With 
lOi  colored  illustrations  on  46  lithographic  plates  and  244  pages  of 
text.     Cloth,  $3.00  net.     In  Smindcrs'  Hand-Atlas  Series. 

THE   NEW   (3d)    EDITION 

Conditions  attending  diseases  of  the  external  eye,  which  are  often  so  complicated, 
have  probably  never  been  more  clearly  and  comprehensively  expounded  than  in 
the  forelying  work,  in  which  the  pictorial  most  happily  supplements  the  verbal 
description.     The  price  of  the  book  is  remarkably  low. 

The  Medical  Record,  New  York 

"  The  work  is  excellently  suited   to  the  student  of  ophthalmology  and   to  the  practising 
physician.     It  cannot  fail  to  attain  a  well-deserved  popularity." 

Haab  and  DeSchweinitz V 
Ophthalmoscopy 


Atlas  and  Epitome  of  Ophthalmoscopy  and  Ophthalmoscopic 
Diagnosis.  By  Dr.  O.  Haab,  of  Zurich.  Edited,  with  additions,  by 
G.  E.  deSchweinitz,  M.  D.,  Professor  of  Ophthalmology,  University 
of  Pennsylvania.  With  152  colored  lithographic  illustrations  and  92 
pages  of  text.     Cloth,  ;^3.oo  net.     In  Saunders'  Hand-Atlas  Series. 

THE  NEW    (2d)    EDITION 

The  great  value  of  Prof.  Haab's  Atlas  of  Ophthalmoscopy  and  Ophthalmo- 
scopic Diagnosis  has  been  fully  established  and  entirely  justified  an  English 
translation.  Not  only  is  the  student  made  acquainted  with  carefully  prepared 
ophthalmoscopic  drawings  done  into  well-executed  lithographs  of  the  most  im- 
portant fundus  changes,  but,  in  many  instances,  plates  of  the  microscopic  lesions 
are  added.     The  whole  furnishes  a  manual  of  the  greatest  possible  service. 

The  Lancet,  London 

"We  recommend  it  as  a  work  that  should  be  in  the  ophthalmic  wards  or  in  the  library  of 
every  hospital  into  which  ophthalmic  cases  are  received." 


SAUNDERS'   BOOKS  OX 


Cradle's 
Nose,  Pharynx,  and  Ear 

Diseases  of  the  Nose,  Pharynx,  and  Ear.  By  Henry  Gradle, 
M.D.,  late  Professor  of  Ophthalmology  and  Otology,  Northwestern 
University  Medical  School,  Chicago.  Octavo  of  547  pages,  illustrated, 
including  two  full-page  plates  in  colors.     Cloth,  ^3.50  net. 

INCLUDING  TOPOGRAPHIC  ANATOMY 

This  volume  presents  diseases  of  the  Nose,  Pharynx,  and  Ear  as  the  author 
has  seen  them  during  an  experience  of  nearly  twenty-five  years.  In  it  are 
answered  in  detail  those  questions  regarding  the  course  and  outcome  of  diseases 
which  cause  the  less  experienced  observer  the  most  anxiety  in  an  individual  case. 
Topographic  anatomy  has  been  accorded  liberal  space. 

Pennsylvania  Medical  Journal 

"This  is  the  most  practical  volume  on  the  nose,  pharynx,  and  ear  that  has  appeared 
recently.  ...  It  is  exactly  what  the  less  experienced  observer  needs,  as  it  avoids  the  confusion 
incident  to  a  categorical  statement  of  everybody's  opinion." 

Kyle's 
Diseases  of  Nose  and  Throat 


Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.  D., 
Professor  of  Laryngology  in  the  Jefferson  Medical  College,  Phila- 
delphia. Octavo,  825  pages;  with  2^8  illustrations,  28  in  colors. 
Cloth,  ^4.50  net;  Half  Morocco^  ^6.00  net. 

JUST  OUT— THE  NEW  (5th)  EDITION 

The  new  {st/i)  edition  of  Dr.  Kyle's  work  shows  an  increase  of  100 pages  Zind. 
some  40  new  illustrations.  The  following  fie^v  articles  have  been  added  :  vaccine 
therapy  ;  lactic  bacteriotherapy;  salvarsan  in  the  treatment  of  syphilis  of  the  upper 
respiratory  tract  ;  sphenopalatine  ganglia  neuralgia  ;  negative  air-pressure  in  ac- 
cessory sinus  disease  ;  chronic  hyperplastic  ethmoiditis  ;  and  congenital  insuffi- 
ciency of  the  palate.  The  tables  of  differential  diagnosis  and  the  prescriptions  are 
striking  points  of  Dr.  Kyle's  book. 

Pennsylvania  Medical  Journal 

"  Dr.  Kyle's  crisp,  terse  diction  has  enabled  the  inclusion  of  all  needful  nose  and  throat 
knowledge  in  this  book." 


URINE  AND   IMPOTENCE. 


O^den  on  the  Urine 


Clinical  Examination  of  Urine  and  Urinary  Diagnosis.     A  Clinical 

Guide  for  the  Use  of  Practitioners  and  Students  of  Medicine  and  Sur- 
gery. By  J.  Bergen  Ogden,  M.  D.,  Medical  Chemist  to  the  Metro- 
politan Life  Insurance  Company,  New  York.  Octavo,  418  pages,  54 
text  illustrations,  and  a  number  of  colored  plates.     Cloth,  ;$3.oo  net. 

THE  NEW  (3d)  EDITION 

In  this  edition  the  work  has  been  brought  absolutely  down  to  the  present  day. 
Urinary  examinations  for  purposes  of  life  insurance  have  been  incorporated,  because. 
a  large  number  of  practitioners  are  often  called  upon  to  make  such  analyses. 
Special  attention  has  been  paid  to  diagnosis  by  the  character  of  the  urine,  the 
diagnosis  of  diseases  of  the  kidneys  and  urinary  passages  ;  an  enumeration  of  the 
prominent  clinical  symptoms  of  each  disease  ;  and  the  peculiarities  of  the  urine 
in  certain  general  diseases. 

The  Lancet,  London 

"  We  consider  this  manual  to  have  been  well  compiled ;  and  the  author's  own  experience, 
sp  clearly  stated,  renders  the  volume  a  useful  one  both  for  study  and  reference." 

Pilcher*s 
Practical  Cystoscopy 

Practical  Cystoscopy.  By  Paul  M.  Pilcher,  M.  D.,  Consulting 
Surgeon  to  the  Eastern  Long  Island  Hospital.  Octavo  of  398  pages, 
with  233  illustrations,  29  in  colors.     Cloth,  $5.50  net. 

DIAGNOSIS  AND  TREATMENT 

Cystoscopy  is  to-day  the  most  practical  manner  of  diagnosing  and  treating 
diseases  of  the  bladder,  ureters,  kidneys,  and  prostate.  To  be  properly  equipped, 
therefore,  you  must  have  at  your  instant  command  the  information  this  book  gives 
you.  It  explains  away  all  difficulty,  telling  you  why  you  do  not  see  something 
when  something  is  there  to  see,  and  telling  you  how  to  see  it.  All  theorj-  has 
been  uncompromisingly  eliminated,  devoting  ever)'  line  to  practical,  needed- 
ever)--day  facts,  telling  you  how  and  when  to  use  the  cystoscope  and  catheter — 
telling  you  in  a  way  to  make  you  know.      The  work  is  complete  in  every  detail. 

Bransford  Lewis,  M.  D.,  St.  Louis  University. 

"  I  am  very  much  pleased  with  Dr.  Pilcher's  '  Practical  Cystoscopy."     I  think  it  is  the  best 

in  the  English  language  now." — April  zj,  igii. 


SAUNDERS'   BOOKS    ON 


Goepp*s 
Dental  State  Boards 

Dental  State  Board  Questions  and  Answers By  R.  Max  Goepp, 

M.  D.,  author  "  Medical  State  Board  Questions  and  Answers."     Octavo 
of  428  pages.      Cloth,  $2.'/^  net. 

COMPLETE  AND  ACCURATE 

This  new  work  is  along  the  same  practical  lines  as  Dr.  Goepp' s  successful  work 
on  Medical  State  Boards.  The  questions  included  have  been  gathered  from  reliable 
sources,  and  embrace  all  those  likely  to  be  asked  in  any  State  Board  examination 
in  any  State.  They  have  been  arranged  and  classified  in  a  way  that  makes  for  a 
rapid  resume  of  every  branch  of  dental  practice,  and  the  answers  are  couched  in 
language  unusually  e.xplicit-:-concise,  definite,  accurate. 

The  practicing  dentist,  also,  will  find  here  a  work  of  great  value — a  work 
covering  the  entire  range  of  dentistry  and  extremely  well  adapted  for  quick 
reference. 

Haab  and  deSchweinitz*s 
Operative  Ophthalmology 

Atlas  and  Epitome  of   Operative    Ophthalmology.       By  Dr.  O. 

Haab,  of  Zurich.  Edited,  with  additions,  by  G.  E.  de  Schweinitz, 
M.  D.,  Professor  of  Ophthalmology  in  the  University  of  Pennsylvania. 
With  30  colored  lithographic  plates,  1 54  text-cuts,  and  375  pages  of 
text.     In  Saimdcrs'  Hand- Atlas  Series.     Cloth,  $3.50  net. 


Dr.  Haab's  Atlas  of  Operative  Ophthalmology  will  be  found  as  beautiful  and 
as  practical  as  his  two  former  atlases.  The  work  represents  the  author' s  thirty 
years'  experien.'.e  in  eye  work.  The  various  operative  interventions  are  described 
with  all  the  precision  and  clearness  that  such  an  experience  brings.  Recognizing 
the  fact  that  mere  verbal  descriptions  are  frequently  insufficient  to  give  a  clear 
idea  of  operative  procedures,  Dr.  Haab  has  taken  particular  care  to  illustrate 
plainly  the  different  parts  of  the  operations. 

Johns  Hopkins  Hospital  Bulletin 

"  The  descriptions  of  the  various  operations  are  so  clear  and  full  that  the  volume  can  well 
hold  place  with  more  pretentious  text-books." 


GENITO-URIXARY   AND    NOSE,     THROAT,     ETC. 


Greene  and  Brooks' 
Genito-Urinary  Diseases 

Diseases  of    the    Genito=Urinary  Organs  and  the   Kidney.      By 

Robert  H.  Greene,  M.  D.,  Professor  of  Gcnito-Urinar}-  Surger}'  at 
Fordham  University ;  and  Harlow  Brooks,  M.  D.,  Assistant  Pro- 
fessor of  Clinical  Medicine,  University  and  Bellevue  Hospital  IMedical 
School.  Octavo  of  639  pages,  illustrated.  Cloth,  $5.00  netj  Half 
Morocco,  S6. 50  net. 

THE  NEW   (3d)  EDITION 

This  new  work  presents  both  the  medical  and  surgical  sides.  Designed  as  a 
work  of  quick  reference,  it  has  been  written  in  a  clear,  condensed  st\-le,  so  that 
the  information  can  be  readily  grasped  and  retained.  Kidney  diseases  are  very 
elaborately  detailed. 

New  York  Medical  JoumeJ 

"  As  a  whole  the  book  is  one  of  the  most  satisfactory  and  useful  works  on  genito-urinaxy 
diseases  now  extant,  and  will  undoubtedly  be  popular  among  practitioners  and  students." 

Gleason  on  Nose,  Throat, 
and  Ear 

A   Manual   of   Diseases  of   the    Nose,  Tliroat,  and    Ear.     By  E. 

Baldwin  Gle.\sox,  M.  D.,  LL.  D.,  Professor  of  Otology,  Medico- 
Chirurgical  College,  Philadelphia.  12mo  of  590  pages,  profusely  illus- 
trated.    Cloth,  S2.50  net. 

JUST  OUT— THE  NEW     3d;  EDITION 

Methods  ot  treatment  have  been  simplified  as  much  as  possible,  so  that  in 
most  instances  only  those  methods,  drugs,  and  operations  have  been  advised 
which  have  proved  beneficial.  A  valuable  feature  consists  of  the  collection  of 
formulas. 

American  Journal  of  the  Medical  Sciences 

"  For  the  practitioner  who  wishes  a  reliable  guide  in  laryngology'  and  otology'  there  are  few 
books  which  can  be  more  heartily  commended." 


American  Text=Book  of  Genito=L'rinary  Diseases,  Syphilis,  and 
Diseases  of  the  Skin.  Edited  by  L.  Boltox  Bangs.  M.  D..  and 
W.  A.  Hardaway,  M.  D.  Octavo,  1229  pages,  300  engravings,  20 
colored  plates.     Cloth,  $7.00  net. 


S.irXD£:J?S'   BOOKS  ON 


Holland's  Medical 
Chemistry  and  Toxicolog>y 

A  Text=Book  of  Medical  Chemistry  and  Toxicology.  By  James 
W.  Holland,  M.  D.,  Professor  of  Medical  Chemistrj'  and  Toxicology, 
and  Dean,  Jefferson  ?kledical  College,  Philadelphia.  Octavo  of  675 
pages,  fully  illustrated.     Cloth,  $3.CK)  net. 

THE  NEW  (3d)  EDITION 

Dr.  Holland's  work  is  an  entirely  new  one,  and  is  based  on  his  forty  years' 
practical  experience  in  teaching  chemistr}'  and  medicine.  It  has  been  subjected  to 
a  thorough  revision,  and  enlarged  to  the  extent  of  some  sixty  pages.  The  additions 
to  be  specially  noted  are  those  relating  to  the  electronic  theory,  chemical  equilib- 
rium, Kjeldahl's  method  for  determining  nitrogen,  chemistn.-  of  foods  and  their 
changes  in  the  body,  synthesis  of  proteins,  and  the  latest  improvements  in  urinary 
tests.     More  space  is  given  to  toxicology  than  in  any  other  text-book  on  chemistry. 

American  Medicine 

"  Its  statements  are  clear  and  terse ;  its  illustrations  well  chosen;  its  development  logical, 
systematic,  and  comparatively  easy  to  follow.  .  .  .  We  heartily  commend  the  work." 

Ivy*s  Applied  Anatomy  and 

Oral  Surg'ery  for  Dental  Students 


Applied   Anatomy  and   Oral   Surgery  for  Dental  Students.     By 

Robert  H.  \\y,  M.D.,  D.D.S.,  Assistant  Oral  Surgeon  to  the  Philadel- 
phia General  Hospital.     i2mo  of  280  pages,  illustrated.     Cloth,  $1.50 

net 

FOR  DENTAL  STUDENTS 

This  work  is  just  what  dental  students  have  long  wanted — a  concise,  practical 
work  on  applied  anatomy  and  oral  surgerj',  written  with  their  needs  solely  in 
mind.  No  one  could  be  better  fitted  for  this  task  than  Dr.  Ivy,  who  is  a  graduate 
in  both  dentistn-  and  medicine.  Having  gone  through  the  dental  school,  he 
knows  precisely  the  dental  student's  needs  and  just  how  to  meet  them.  His 
medical  training  assures  you  that  his  anatomy  is  accurate  and  his  technic  modem. 
The  text  is  well  illustrated  with  pictures  that  you  will  find  extremely  helpful, 

H.  P.  Ktlhn,  M.D.,  Western  Dental  College,  Kansas  City. 

"  I  am  delighted  with  this  compact  little  treatise.     It  seems  to  me  just  to  fill  the  bill." 


CHEMISTRY,  SKIX,  AXD   VENEREAL   DISEASES.  15 

American  Pocket  Dictionary  New   8th   Edition 

The  American  Pucket  Medical  Dictionary.    Edited  by  W.  A. 

Newman  Borland,  M.  D.,  Editor  "American  Illustrated  Medical 

Dictionary."     Containing-  the  pronunciation  and  definition  of  the 

principal  words  used  in  medicine  and  kindred  sciences.    677  pages. 

Flexible  leather,  with  gold  edges,  $1.00  net;  with  thumb  index, 

^1.25  net. 

James  W.  Holland.  M.  D., 

Professor  of  Medical  Chemistry  and  Toxicology,  and  Dean,  Jefferson  Medical  College 
Philadelphia,  ^  ' 

"  I  am  struck  at  once  with  admiration  at  the  compact  size  and  attractive  exterior.  ] 
can  recommend  it  to  our  students  without  reserve." 

Stelwagon's  Essentials  of  Skin  7th  sedition 

Essentials  of  Diseases  of  the  Skin.  By  Henry  W.  Stel- 
wagon,  M.  D.,  Ph.D.,  Professor  of  Dermatology  in  the  Jeffer- 
son Medical  College,  Philadelphia.  Post-octavo  of  29 1  pages, 
with  72  text-illustrations  and  8  plates.  Cloth,  $1.00  net.  In 
Saunders'  Question-  Compend  Series. 
The  Medical  News 

"  In  line  with  our  present  knowledge  of  diseases  of  the  skin.  .  .  .  Continues  to  main- 
tain the  high  standard  of  excellence  for  which  these  question  compends  have  been  noted." 

Wolffs  Medical  Chemistry  New   7th)  Edition 

Essentials  of  Medical  Chemistry,  Organic  and  Inorganic. 
Containing  also  Questions  on  Medical  Physics,  Chemical  Physiol- 
ogy, Analytical  Processes,  Urinalysis,  and  Toxicology.  By  Law- 
rence Wolff,  M.  D.,  Late  Demonstrator  of  Chemistr}',  Jefferson 
Medical  College.  Revised  by  A.  Ferree  Wttmer,  Ph.  G.,  M.  D., 
Formerl)-  Assistant  Demonstrator  of  Physiology,  University  of 
Pennsylvania.  Post-octavo  of  222  pages.  Cloth,  31.00  net.  In 
Saimders^  Qiiestion-Compend  Series. 

Bliss*  Qualitative  Chemic&l  Analysis 

Qualitative  Chemical  Analysis.  B}-  A.  R.  Bliss,  Jr.,  Ph.  G., 
M.  D.,  Professor  of  Chemistr>'  and  Pharmacy,  Birmingham 
Medical  College,  Alabama.  Octavo  of  250  pages.  Cloth,  S2.00 
net. 

Vecki's  Sexual  Impotence  New  (4thj  Edition 

Sexual  Lmpotence.  By  Victor  G.  Vecki,  M.  D.,  Consulting 
Genito-Urinary  Surgeon  to  Mt.  Zion  Hospital,  San  Francisco. 
i2mo  of  400  pages.     Cloth,  ^2.25  net. 

Johns  Hopkins  Hospital  Bulletin 

"A  scientific  treatise  upon  an  important  and  much  neglected  subject.  .  .  .  The 
treatment  of  impotence  in  general  and  of  sexual  neurasthenia  is  discriminating  and 
judicious." 


14  SAUXDERS'    BOOKS   ON 


Second 
Edition 


Wells*   Chemical   Pathology 

Chemical  Pathology.  Being  a  discussion  c^  General  Path- 
ology from  the  Standpoint  of  the  Chemical  Processes  Involved. 
By  H.  Gideon  Wells,  Ph.  D.,  M.  D.,  Assistant  Professor  of 
Pathology  in  the  University  of  Chicago.  Octavo  of  6i6  pages. 
Cloth,  $3.25  net. 

Wm.   H.  Welch,   M.  D.,  Professor  of  Pathology,  Johns  Hopkins  University. 

"  The  work  fills  a  real  need  in  the  English  literature  of  a  very  important  subject,  and 
I  shall  be  glad  to  recommend  it  to  my  students." 


The  New  (2di  Edition 


Saxe*s  Urinalysis 

Examination  of  the  Urine.  By  G.  A.  De  Santos  Saxe,  M.  D., 
formerly  Instructor  in  Genito-Urinary  Surgery,  New  York  Post- 
graduate Medical  School  and  Hospital.  i2mo  of  448  pages,  fully 
illustrated.     Cloth,  31.75  net. 

Ftzsiaa  Caster  Wood,  M.  D.,    Adjunct  Professor  of  Clinical  Pathology,  Columbia   Uni- 
versity. 

"  It  seems  to  me  to  be  one  of  the  best  of  the  smaller  works  on  this  subject ;  it  is, 
indeed,  better  than  a  good  many  of  the  larger  ones." 

deSchweinitz  and  Randall   on  the  Eye,  Ear, 
Nose,  and  Throat 

American  Text-Book  of  Diseases  of  the  Eye,  Ear,  Nose,  and 
Throat.  Edited  by  G.  E.  de  Schweimtz,  M.D..  and  B.  Alex- 
ander Randall,  ^I.D.  Imperial  octavo,  1251  pages,  with  766 
illustrations,  59  of  them  in  colors.  Cloth,  $7.00  net;  Half  Mo- 
rocco, $8.50  net 

Griinwald  and  Grayson  on  the  Larynx 

Atlas  and  Epitome  of  Diseases    of  the  Larynx.     By  Dr.  L. 

Grunwald,  of  Munich.  Edited,  with  additions,  by  Charles  P. 
Grayson,  M.D.,  .University  of  Pennsylvania.  With  107  colored 
figures  on  44  plates,  25  text-cuts,  and  103  pages  of  text.  Cloth, 
$2.50  net.     In  Saioidcrs   Ha)id-Atlas  Series. 

Mracek  and  Stelwag'on's  Atlas  of  Skin         l^^iSon 

Atlas  and  Epitome  of  Diseases  of  the  5kin.  By  Prof.  Dr. 
Franz  Mracek,  of  Vienna.  Edited,  with  additions,  by  Henry 
W.  Stelwagon,  M.D.,  Jefferson  Medical  College.  With  "j  col- 
ored plates,  50  half-tone  illustrations,  and  280  pages  of  text.  In 
Saunders'  Harid-Atlas  Series.     Cloth,  $400  net. 


EYE,    EAR,    NOSE,    AND    THROAT.  15 


deSchweinitz    and    Holloway   on   Pulsating*    Exoph- 
thalmos 

Pulsating  Exophthalmos.  An  analysis  of  sixty-nine  cases  not  pre- 
viously analyzed.  By  George  E.  deSchweinitz,  M.  D.,  and  Thomas 
B.  Holloway,  M.  D.     Octavo  of  125  pages.     Cloth,  $2.00  net. 

This  monograph  consists  of  an  analysis  of  sixty-nine  cases  of  this  affection 
not  previously  analyzed.  The  therapeutic  measures,  surgical  and  otherwise, 
which  have  been  employed  are  compared,  and  an  endeavor  has  been  made 
to  determine  from  these  analyses  which  procedures  seem  likely  to  prove  of 
the  greatest  value.  It  is  the  most  valuable  contribution  to  ophthalmic  liter- 
ature within  recent  years. 

Brituh  Medical  Joum&l 

"  The  book  deals  very  thoroughly  with  the  whole  subject  and  in  it  the  most  complete  account  <A 
the  disease  will  be  found." 

Jackson  on  the  Eye  The  New  (2d)  Edition 

A  Manual  of  the  Diagnosis  and  Treatment  of  Diseases  of  the 
Eve.  By  Edward  Jackson,  A.  M.,  M.  D.,  Professor  of  Ophthalmology, 
University  of  Colorado.  i2mo  volume  of  615  pages,  with  184  beautiful 
illustrations.     Cloth,  ^2.50  net. 

The  Medic&l  Record,  New  York 

"  It  is  truly  an  admirable  work.  .  .  .  Written  in  a  clear,  concise  manner,  it  bears  evidence  of  the 
author's  comprehensive  grasp  of  the  subject.  The  term  '  multum  in  parvo'  is  an  appropriate  one  to 
apply  to  this  work." 

Grant  on   Face,   Mouth,   and  Jaws 

A  Text-Book  of  the  Surgical  Principles  and  Surgical  Diseases 
OF  the  Face,  Mouth,  and  Jaws.  For  Dental  Students.  By  H.  Horace 
Grant,  A.  M.,  M.  D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
Hospital  College  of  Medicine,  Louisville.  Octavo  of  231  pages,  with 
68  illustrations.     Cloth,  $2.50  net. 

Preiswerk  and  Warren's  Dentistry 

Atlas  and  Epitome  of  Dentistry.  By  Prof.  G.  Preiswerk,  of 
Basil.  Edited,  with  additions,  by  George  W.  Warren,  D.D.S.,  Pro- 
fessor of  Operative  Dentistry,  Pennsylvania  College  of  Dental  Surgery, 
Philadelphia.  With  44  lithographic  plates,  152  text-cuts,  and  343  pages 
of  text.      Cloth,  $3.50  net.      Jn  Saunders'  Atlas  Series. 

Asher's  Chemistry  and  Toxicology 

Chemistry  and  Toxicology  for  Nurses.  By  Philip  Asher,  Ph.G., 
M.  D.,  Dean  and  Professor  of  Chemistry,  New  Orleans  College  of  Phar- 
macy.     i2mo  of  190  pages.     Cloth,  $1-25  net. 


1 6  SAUXDERS'   BOOKS  ON 

Wolfs  Examination  of  Urine 

A  Laboratory  Handbook  of  Physiologic  Chemistry  and 
Urine-examination.  By  Charles  G.  L.  Wolf,  M.  D.,  Instructor  in 
Physiologic  Chemistry,  Cornell  University  Medical  College,  New 
York.  i2mo  volume  of  204  pages,  fully  illustrated.  Cloth,  $\.2^  net. 
British  Medical  Journal 

"  Tlie  methods  of  examining  the  urine  are  very  fully  described,  and  there  are  at  the 
end  of  the  book  some   extensive   tables  drawn  up  to  assist  in  urinary  diagnosis." 

Jackson's  Essentials  of  Eye  Third  Revised  Edition 

Essentials  of  Refraction  and  of  Diseases  of  the  Eye.  By 
Edward  Jackson,  A.  M.,  M.  D.,  Emeritus  Professor  of  Diseases  of 
the  Eye,  Philadelphia  Polyclinic.  Post-octavo  of  261  pages,  82  illus- 
trations. Cloth,  $1.00  net.  In  Saiuiders'  Question- Compcnd  Series. 
Johns  Hopkins  Hospital  Bulletin 

"  The  entire  ground  is  covered,  and  the  points  that  most  need  careful  elucidation 
are  made  clear  and  easy." 

Gleason*s  Nose  and  Throat  Fourth  Edition.  Revbed 

Essentials  of  Diseases  of  the  Nose  and  Throat.  By  E.  B. 
Gleason,  S.  B.,  M.  D..  Clinical  Professor  of  Otology,  Medico- 
Chirurgical  College,  Philadelphia,  etc.  Post-octavo,  241  pages,  112 
illustrations.  Cloth,  $1.00  net.  /;/  Saunders'  Question  Coinpends, 
The  Lancet,  London 

"The  careful  description  which  is  given  of  the  various  procedures  would  be  sufficient 
to  enable  most  people  of  average  intelligence  and  of  slight  anatomical  knowledge  to 
make  a  very  good  attempt  at  laryngoscopy." 

Gleason*s  Diseases  of  the  Ear  Third  Edition,  Revised 

Essentiai^  of  Diseases  of  the  Ear.     By  E.  B.  Gleason,  S.  B., 
.    M.  D.,  Clinical  Professor  of  Otology,  Medico-Chirurgical  College, 
Phila.,  etc.     Post-octavo   volume  of  214  pages,  with    114  illustra- 
tions.    Cloth,  $1.00  net.     In  Saunders'  Questioii-Compend  Series. 
Bristol  Medico-Chirurgical  Journal 

"  We  know  of  no  other  small  work  on  ear  diseases  to  compare  with  this,  either  in 
freshness  of  style  or  completeness  of  information." 

Wilcox  on  Genito-Urinary  and  Venereal  Diseases 

The   New   (2d)   Edition 

Essentials  of  Genito-Urinary  and  Venereal  Diseases.  By 
Starling  S.  Wilcox,  M.  D.,  Lecturer  on  Genito-Urinary  Diseases 
and  Syphilology,  Starling-Ohio  Medical  College,  Columbus.  i2mo 
of  321  pages,  illustrated.     Cloth,  ^i. 00  net.     Saunders'  Compends. 

Stevenson's  Photoscopy 

Photoscopy  (Skiascopy  or  Retinoscopy).  By  Mark  D.  Stev- 
enson, M.  D.,  Ophthalmic  Surgeon  to  the  Akron  City  Hospital. 
i2mo'of  126  pages,  illustrated.  Cloth,  $1.25  net. 

Edward  Jackson,  M.  D.,  University  of  Colorado. 

"  It  is  well  written  and  will  prove  a  valuable  help.  Your  treatment  of  the  emergent 
pencil  of  rays,  and  the  part  falling  on  the  examiner's  eye,  is  decidedly  better  than  any 
previous  account." 


University  of  California 

SOUTHERN  REGIONAL  LIBRARY  FACILITY 

405  Hilgard  Avenue,  Los  Angeles,  CA  90024-1388 

Return  this  material  to  tfie  library 

from  which  it  was  borrowed. 


165  UO 


o 


C3 


00 


^5 


WI  100 

G211d 

1915 
Gant,  Camuel  G 

Diarrheal,  inflammatory,  obstructive, 
and  parasitic  diseases  of  the 
gastro-intestinal  tract 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


il!>!!il|!!llillili|ll!l|i!ll|lini!!!!|ill||lll|i!!l!lll!ll!!in|lll!!!l!!t!!l)!!l!!ll!!i!li|lll!l^  | 

!!l!!illll!li!illllllllll!!lill!ll!!!l!lll!!!!tl!lli;il!!llllllllll!llillllllH 


Ml   ilili! 


Mj  I      !    j  J 


